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MAA 104


What is a symptom felt by the patient, but not observed by an examiner? Subjective symptom.
What are conclusions drawn by the physician from an interpretation of data? Medical Impression
What is an objective symptom? One that can be observed or measured by an examiner
What is prognosis? The probably course and outcome of a patient's condition
What is a report of the physician's objective findings? Physical Exam Report
What is a collection of subjective and objective datat about a patient? Health history report
What is chorological Order? Place in order of time; usually the most recent is placed foremost
What is the chief complaint? Mand readon for the visit to the medical office. In the patient's own words
Describe a narrative: A paragraph indicating the contact with the patient, what was done for the patient, and the outcome of any action
What is a referral? Instructions to transfer a patient's care to a specialist
What is a diagnosis? A disease or condition indentified in a person
Describe demographic data: Information necessary for administrative purposes i.e. Name, Address, Phone Number, Marital Status, Gender, Race
Describe POMR Problem Oriented Medical Record: A common method of compiling information that lists each problem at the beginning of the chart, giving it a number and referring to that problem by number throughout the chart
List ways to maintain security of information: Train all employees on confidentiality and HIPAA Conduct routine audits of movement through records Prepare a back-up plan for when the system is down
A patient complains of a headache for the last two days. This is part of which part of SOAP charting? Part of the subjective patient information
Why should you keep medical records? Used in malpractice suits. They evaluate the quality of treatment. Provide continuity of care. Legal document. Can be subpoenaed.
Which title of HIPAA covers health insurance access, portability and renewal? Title 1
True/False: HIPAA requires that each office designate at least one employee to oversee and coordinate various aspects of compliance True
How do you document an event after the actual time that it happened? Document with today's date, but chart late entry for the date and time it actually happened
What are covered entities? Health Insurance Companies, Clearinghouses. Under HIPAA it is all who must adhere to their regulations.
What are 4 component parts of a POMR chart? Database, Problem List, Treatment Plan, Progress Notes
What are flow sheets? Record of ongoing measurements in a graph or chart form.
Abbreviations used in medical records should be: Accepted for use by the facility for office. Standard Medical Abbr.
Is it ok to release medical imformation over the phone? No
Should correction fulid be used in medical records? No
What is the Golden Rule of documentation? If it isn't documented, it didn't happen.
The physical record belongs to who? The physician (Or clinic if ti's a group practice)
When is the only time the original record should be released? When subpoenaed by a court of law
Release of patient Information Cannot be given over the phone Should not be transmitted with SSL or encryption
How to correct a medical record entry Draw a single line through the error, make correction, sign and date it
Chart Status: Active: Patients currently being seen on a regular basis Inactive: Patients who have not been seen recently Closed: Deceased patient or those who have moved or dismissed
Protection of files: Back-up regularly (nightly) Store back-ups off premises Do not open email from epople you don't know
AMA recommedation: Set security levels to limit entry to all functions Store disks in a bank safe-deposit box Prepare a back-up plan if system is down
SOAP Charting Subjective: What the patient tells you Objective: What you can see, measure Assessment: Diagnosis Plan: for treatment
Progness Notes Documentation of each patient encounter, inlcluding phone calls and prescription refills
Advance Directive Instructions regarding end of life decisions
HIPAA TITLE 1: Covers health insurance access, portability and renewal. Those who must fall the rules: Covered Entities HIPAA officer: Oversees and coordinates all aspects of compliance
Created by: JDenning8984