CMAA Medical Records Management 2 — Questions and Answers
Question 1: What is the SOAP format in medical documentation?
- Scheduling, Operations, Administration, Personnel
- Subjective, Objective, Assessment, Plan (Correct answer)
- Standard, Organized, Accessible, Protected
- Summary, Outcomes, Analysis, Prognosis
Correct answer: Subjective, Objective, Assessment, Plan
SOAP stands for Subjective (patient symptoms), Objective (measurable findings), Assessment (diagnosis), and Plan (treatment).
Subjective: patient complaints, symptoms, history. Objective: vital signs, exam findings, lab results. Assessment: clinical impression or diagnosis. Plan: medications, tests, referrals, follow-up. CMAAs should understand SOAP format to locate information in records.
Question 2: How should corrections be made to a paper medical record?
- Use correction fluid
- Remove and replace the page
- Draw a single line through the error, write correction, initial and date (Correct answer)
- Erase and rewrite
Correct answer: Draw a single line through the error, write correction, initial and date
Draw a single line (keeping original legible), write the correction, and add date, time, and initials.
Never use correction fluid, erase, or remove pages, as these destroy the audit trail and suggest falsification. EHRs maintain their own audit trails. In legal proceedings, altered records severely damage a provider's defense. Follow these procedures meticulously.
Question 3: What is the purpose of an EHR audit trail?
- Track financial transactions
- Record every access, modification, and action on patient records (Correct answer)
- Monitor internet usage
- Schedule system backups
Correct answer: Record every access, modification, and action on patient records
Audit trails log every user action: who accessed a record, when, what changes were made, and from where.
Required under HIPAA's Security Rule. Records: user ID, timestamp, action performed, data accessed or changed, workstation used, and original/modified values. Purposes: detecting unauthorized access, compliance investigations, legal evidence, and training needs identification.
Question 4: What must be obtained before transferring records to another provider?
- Payment for the transfer fee
- A signed authorization specifying what records to release and to whom (Correct answer)
- Verbal confirmation from receiving provider
- A court order
Correct answer: A signed authorization specifying what records to release and to whom
A signed patient authorization must specify what information to release, to whom, and for what purpose.
Valid authorization needs: description of info to be disclosed, authorized parties, receiving parties, purpose, expiration date, and patient signature. Verify completeness, prepare requested records, log the disclosure, and send securely within state-required timeframes.
Question 5: What filing system assigns each patient a sequential number at registration?
- Alphabetical filing
- Terminal digit filing
- Straight numeric filing (Correct answer)
- Subject filing
Correct answer: Straight numeric filing
Straight numeric filing assigns consecutive numbers in registration order and files in ascending sequence.
Simple but has drawbacks in larger practices: filing activity concentrates at the end, and misfiling is common with similar large numbers. Terminal digit filing distributes files evenly. Alphabetical filing uses names but has common-name issues. Most modern practices use EHR systems.
Question 6: What is the purpose of a release of information (ROI) log?
- Track patient hospital releases
- Document every instance of patient record disclosure (Correct answer)
- Log staff breaks
- Record policy release dates
Correct answer: Document every instance of patient record disclosure
The ROI log documents every disclosure including who requested records, what was released, when, to whom, and the purpose.
HIPAA requires accounting of disclosures going back six years on patient request. The log includes: date, recipient, PHI description, purpose, processor, and transmission method. TPO and authorized disclosures are exempt from accounting but many practices track all disclosures as best practice.
CMAA Medical Records Management 2
What is the SOAP format in medical documentation?