MAA 104 Word Scramble
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Question | Answer |
Why do we keep records? #1 | Legal Use. Medical records are legal documents and can be subpoenaed. They can be used in malpractice suits. |
Why do we keep records? #2 | Medical records evaluate quality of treatment |
Why do we keep records? #3 | Provide for continuity of care. |
Why do we keep records? #4 | Allows for communication between provider and staff. |
Why do we keep records? #5 | Documents the patient's original evaluation. |
Why do we keep records? #6 | Reports any changes in the patient's condition |
Golden Rule of Documentation? | If it didn't get documented it didn't happen. |
Release of Information | Should not be done over the phone. Should not be transmitted unless over a secure line or it is encrypted. |
Ownership of records | In private practice where there is ONE physician: The physician owns the physical chart. In group practice, the clinic owns the physical chart. The PATIENT owns the information in the chart. |
Correction of a record | Never use white out. Draw a single line through the error. Make the correction. Sign and date the correction. |
Chart Status: Active | Patients currently being seen |
Chart Status: Inactive | Patients not been seen recently (up to 3 yrs) (After 3 yrs, New Patient) |
Chart Status: Closed | Deceased patients, Patients that won't be seen anymore (Moved, Fired, Etc.) |
Abbreviations | Only use those accepted by facility. Standard Medical Abbreviations. |
AMA Recommendations | Train Employees in HIPAA & Confidentiality. Conduct audits of employee movement through records. Prepare back up plan |
Security | Don't open emails that you don't recognize the sender. Change passwords |
Flow Sheets | Record ongoing measurement |
POMR chart | Problem oriented medical record. Listed and assigned numbers. Recognize component list: Database, problem list, treatment plan, progress notes |
SOAP chart | S)ubjective Patient Info - What pt. tells you is worng O)bjective clinical measurements - BP, weight, temp A)ssessment/Diagnosis P)lan for treatment |
Late Documentation | Document note with current date but chart for late entry for date and time of occurrence. |
Progress Notes | Documentation of every patient encounter. Including phone calls and prescription refills. |
Advance Directive | Living Will |
HIPAA Title 1 | Covers health insurance access and portability & renewal. Those who fall under are called covered entities. Covered entities are: Healthcare Workers, Insurance Cos., Clearinghouses. HIPAA officer: oversees all aspects of compliance |
Demographic Info | |
Narrative: | Paragraph indicating contact with patient |
Diagnosis: | Disease or condition identified in a patient |
Chronological Order: | Place in order of time (date) most recent |
Referral: | Instruction to transfer a patient's care to a specialist. |
Medical Impression: | Conclusions drawn by the physician from the interpretation of data |
Health History Report: | Provides subjective data to assist in diagnosis. |
Chief Complaint: | The problem that is causing the patient to seek medical treatment (in their own words). Found in the clinical section of the chart. Main reason foe the medical office visit. |
Objective Symptom: | A symptom that can be observed by the examiner(or measured) i.e. temp, rash, BP, etc. |
Subjective Symptom: | Symptom felt by the examiner, but not observed by examiner. |
Physical Exam Report: | Report of a physician's objective findings. |
Prognosis: | Probably course and outcome of a patient's condition. |
Business Letters | Use only standard abbreviations |
Clearinghouse | Entity that receives, reviews, sends and manages claims |
Written correspondence | |
How do you secure email? | With an encryption feature |
How many formats for business letters? | 4 (clearinghouses, record classification, chief complaint, medical records) |
Record Classification | Active, Inactive, Closed |
Chief Complaint | Subjective |
Patient registration -Administrative info | Collecting demographics does not include clinic info |
Can we copy anything on the internet? | NO. Copywrite laws apply. |
Created by:
JDenning8984
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