AMCA Patient Documentation 2 — Questions and Answers
Question 1: Which principle requires that medical records document only information relevant to the patient's care?
- Completeness
- Pertinence (Correct answer)
- Accuracy
- Timeliness
Correct answer: Pertinence
Pertinence means documenting only information that is relevant to the patient's diagnosis and treatment.
Question 2: When correcting an error in a paper medical record, the correct method is to:
- Use correction fluid to cover the mistake
- Draw a single line through the error, initial, date, and write the correction (Correct answer)
- Erase the error completely and rewrite
- Black out the error with a permanent marker
Correct answer: Draw a single line through the error, initial, date, and write the correction
A single line through the error with initials, date, and correction preserves the original entry and maintains record integrity.
Question 3: A patient's allergy to penicillin should be documented in which section of the medical record?
- Social history
- Chief complaint
- Allergy and medication list (Correct answer)
- Review of systems
Correct answer: Allergy and medication list
Allergies are recorded in the allergy and medication list section to ensure they are prominently visible to all providers.
Question 4: What does the abbreviation 'NPO' mean in patient documentation?
- No prior operations
- Nothing by mouth (Correct answer)
- Normal pulse oximetry
- Non-productive output
Correct answer: Nothing by mouth
NPO stands for 'nil per os,' a Latin phrase meaning nothing by mouth, used before surgeries or procedures.
Question 5: Which document authorizes a medical assistant to release patient records to an insurance company?
- Advance directive
- Signed authorization for release of information (Correct answer)
- Subpoena
- HIPAA privacy notice
Correct answer: Signed authorization for release of information
A signed authorization for release of information is required before disclosing patient records to third parties including insurers.
Question 6: In SOAP note format, the physical examination findings are recorded under which section?
- Subjective
- Objective (Correct answer)
- Assessment
- Plan
Correct answer: Objective
Objective data includes measurable findings such as vital signs, physical exam results, and lab values.
Question 7: A patient refuses a recommended procedure. The medical record should document:
- Only the procedure that was performed
- The refusal, education provided, and patient's understanding (Correct answer)
- Nothing, since the procedure was not done
- The physician's opinion about the refusal
Correct answer: The refusal, education provided, and patient's understanding
Documenting informed refusal protects the practice legally and shows that the patient was educated about risks of declining care.
AMCA Patient Documentation 2
Which principle requires that medical records document only information relevant to the patient's care?