Medical Records Assignment Flashcards
exam study (22 cards)
The original record, along with x-ray films and laboratory reports or electrodiagnostic test, is the property of the
Veterinarian Hospital
Major medical disorders experienced by a patient during its lifetime are included in the _____ list, which servers as an index to the patient’s medical history.
Master Problem
What filing system operates generally by state or country and then alphabetically or numerically by account name or number>
Geographic filing
“Heart rate, respiration rate, skin refraction time (skin turgor)” belongs to _____ in the medical record?
Objected
Which of the following medical record formats take more time to compile? Because it makes available more historical information, this fromat supports case planning and provides protection in the event of lintigation.
Problem- Oriented medical records
Which of the following is not considered a legal reason for maintaining medical records?
hospital employed accountants and attorneys require them
Recommended information such as a patient’s date of birth, preventative medication program, behavior, previous conditions, and known allergies, is included as part of the ________ in a comprehensive medical record.
Previous history
Medical records
Should be retained even if the client moves away
To correct a mistake in a medical record
Draw a line through it, label it as an error, and initial it.
What color ink is most appropriate to use when marking in medical records?
Black because it photocopies well and blue
Which separated financial record consists of a chronological listing of every daily transaction? This includes client and patient identification, services rendered, fee charges and amount paid.
Daybook
A comprehensive medical record should contain all of the following except
Patient’s pedigree history
Which system’s greater benefit’s is speed of filling and finding? although this system requires a cross index, it can increase efficiency by 40% to 50%.
Numeric filing
“Awake, standing, wagging tail” belongs to ______ in the medical record?
Subjective
Discussing a patients records with outside parties
Is a breach confidentiality
Prescriptions
Should be recorded, and records should be maintained
A signed authorization form from the patient’s owner is not needed before any information in the medical record can be released to
Government agencies
Which of the following, logs is legally required?
Controlled substances
Each practice or clinic sets its own rules for purging active records. How long are records generally kept in a practice?
3 years
medical records in the veterinarian practice are considered ___________, so they must be completely accurate and written legibly in blue or black ink.
A legal document
Which part pf the POVMR is like a table of contents or index for the record?
Problem list
Cage cards should contain all of the following information with the exception of
Date of last visit
