Medical Records Management Flashcards
6 cards from real CMAA practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 6 Medical Records Management flashcards as text
What is the SOAP format in medical documentation?
Answer: Subjective, Objective, Assessment, Plan
SOAP stands for Subjective (patient symptoms), Objective (measurable findings), Assessment (diagnosis), and Plan (treatment).
How should corrections be made to a paper medical record?
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.
What is the purpose of an EHR audit trail?
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.
What must be obtained before transferring records to another provider?
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.
What filing system assigns each patient a sequential number at registration?
Answer: Straight numeric filing
Straight numeric filing assigns consecutive numbers in registration order and files in ascending sequence.
What is the purpose of a release of information (ROI) log?
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.