CMAA Medical Records Management 2

Question 1

What is the SOAP format in medical documentation?

Accepted Answer

Subjective, Objective, Assessment, Plan

Answer

SOAP stands for Subjective (patient symptoms), Objective (measurable findings), Assessment (diagnosis), and Plan (treatment).

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

Draw a single line (keeping original legible), write the correction, and add date, time, and initials.

Question 3

What is the purpose of an EHR audit trail?

Accepted Answer

Record every access, modification, and action on patient records

Answer

Audit trails log every user action: who accessed a record, when, what changes were made, and from where.

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

A signed patient authorization must specify what information to release, to whom, and for what purpose.

Question 5

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

Accepted Answer

Straight numeric filing

Answer

Straight numeric filing assigns consecutive numbers in registration order and files in ascending sequence.

CMAA - Certified Medical Administrative Assistant Practice Test