CMAA Medical Records Management 2

Question 1

What is the SOAP format in medical documentation?

Accepted Answer

Subjective, Objective, Assessment, Plan

Answer

Scheduling, Operations, Administration, Personnel

Answer

Standard, Organized, Accessible, Protected

Answer

Summary, Outcomes, Analysis, Prognosis

Question 2

How should corrections be made to a paper medical record?

Accepted Answer

Draw a single line through the error, write correction, initial and date

Answer

Use correction fluid

Answer

Remove and replace the page

Answer

Erase and rewrite

Question 3

What is the purpose of an EHR audit trail?

Accepted Answer

Record every access, modification, and action on patient records

Answer

Track financial transactions

Answer

Monitor internet usage

Answer

Schedule system backups

Question 4

What must be obtained before transferring records to another provider?

Accepted Answer

A signed authorization specifying what records to release and to whom

Answer

Payment for the transfer fee

Answer

Verbal confirmation from receiving provider

Answer

A court order

Question 5

What filing system assigns each patient a sequential number at registration?

Accepted Answer

Straight numeric filing

Answer

Alphabetical filing

Answer

Terminal digit filing

Answer

Subject filing

Question 6

What is the purpose of a release of information (ROI) log?

Accepted Answer

Document every instance of patient record disclosure

Answer

Track patient hospital releases

Answer

Log staff breaks

Answer

Record policy release dates