Question | Answer |
What is the diference between medical record and medical report. | Report - One sheet stating result of exam. Record - complete set of patient information. |
Determination of a disease | Diagnosis |
The study of the causes of a disease. | Etiology |
Forcast of the outcome of a illness. | Prognosis |
A sign is what kind of information | objective |
A symptom is what kind of information | Subjective |
What does SOAP stand for? | Subjective, Objective, Assessment and Plan |
What do you do first to correct an error? | Put a single through the mistake |
What do you do second to correct an error? | Write 'error' above mistake |
What do you do third to correct an error? | Near error you write the date including the year and your intitnals. |
What is the last step to correcting a mistake? | Write the correct information |
List three benefits of shingling | 1 - saves space 2 - Prevents loss of records 3- allows for the most recent report to be readily available |
Te SOAP approach of writing progress notes is known as what method of record keeping | Traditional |
How should reports be placed in a patient's chart | Reverse chronogical order |
First item medical records are used for | Patient education |
Second item medical records are used for | Research |
Third item medical records are used for | Evaluate |
What does congenital mean | Birth defect |
Are congenital defects subjective or objective | They can be both |
What is a pocket Call Record | Doctor carries to out of office visit |
Is the condition of a patient at the time of termination of treatment objective or subjective | objective |
Should a doctor chart the condition of a patient when treatment is terminated | Yes |
What should happen before any transcribed notes or lab reports are placed in patients medical record? | Doctor should intitial |
What does POMR stand for | Problem Oriented Medical Record |
Define percussion | Tapping done with fingers for sounds |
Define inspection | Exam with eyes |
Define Palpation | Exam by feeling |
Define Auscultation | Listening to sounds with stethoscope |
Is there a different in how you correct handwritten or typewritten errors | No |
To show a mutual relationship | correlation |
Determation of the nature / cause of a disease | Diagnosis |
To see or understand a difference between two things | Discernible |
Being an indispensable part of a whole | Integral |
complete set of patient information | Medical record |
Results of an exam | Medical Report |
Define objective | Perceptible to the observer |
An inference from what has been seen or heard | Observation |
Competency as a result of training & experience | Proficiency |
Records of patient visits, phone calls, progress & treatment that are inserted into the patients chart | Progress notes |
objective evidence of disease discoverable by dr. | Sign |
Fings perceptible only by the effected person | Subjective |
Any perceptible change in the body or its functions | Symptom |