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Medical Admin

What is the common method of filing? Alphabetic
What best describes the proper way to index personal names? (Last name) (First name) (MI)
Hyphenated names are considered what? one unit
Put in order: 1)Sr. 2)lll 3)4th 4)11 5)Jr. 6)5th 1)4th 2)5th 3)ll 4)l 5)Jr. 6)Sr.
What is the importance of medical records accuracy? Critical for smooth functioning and for legal issues.
What office tool helps to ensure charts may be tracked down when borrowed? An Outguide- paper or file that lets someone know where a patients file is and when it will be returned.
Rule 3 of filing? Nothing before something
What is indexing? Placing items in filing order.
What is the name of a mark placed on a document after it is determined that no further follow up is needed? Who makes that mark? Release Mark; Physician or Provider
S in SOAP meaning Subjective- what patients c/c is and symptoms
O in SOAP meaning Objective-signs, what you can see
A in SOAP meaning Assessment- diagnosis
P in SOAP meaning What the physician's plan is to make patient better.
Describe in the proper way to correct an error in a chart Put a single line going thru the word with initial over it.
What is the term used for the main reason for a patients visit? Chief Complaint. c/c
Subjective findings are also known as Symptoms
Objective findings are also known as Signs
What is the information an out guide should contain besides the date a chart was removed? Why is it being removed, Who has removed it, where did it go to, when will it return.
Heredity tendencies Family History (FH)
Tends to detect conditions other than those covered in present Review of Systems
Hobbies, interests, methods of exercise Social History
Covers dates and quests regarding previous complaints Past History
Eating, drinking, smoking and sleeping habbits Social History
Typically reason for visit Chief Complaint
Conclusion physician reaches after evaluating all findings Diagnosis
X-rays, Blood work, UA Laboratory Reports
PMHx reports, Physical Exams, Follow-up notes Clinical notes
Outside letters from other physicians, clinical offices Correspondeneces
Insurance related papers, requests for transfer or medical records, anything not related to direct treatment of the patient. Miscellaneous
Release Mark Used to let staff know an item was signed off and may be filed in the chart.
Purging The method of removing files from the office that are no longer in use.
Out guide A tool used to insure that records are tracked when borrowed.
POMR Method by which problems are identified by the number that corresponds to the problem.
ROS Guide to general health that tends to detect condition other than those covered by present illness
Symptom Perceptible only to patient
Cardinal Symptom Symptom of the greatest significance to the overall condition.
SOMR Groups information in the chart according to category.
Signs Perceptible to another person.
Cross Referencing Card or sheet that may be used when name is indexed in more than one way
Hyphenated names are separated into 2 units for filing False
North West is the same as Northwest in filing False
Symbols in company names are spelled out. True
Punctuation is ignored in filing, True
Records are retained for 7 years and certain files put on microfilm before destroying True
MA's do a review of systems before the physician sees the patient False
The last name ST. Mark would be spelled out and indexed as Saint Mark False
CC Chief Complaint
DX Diagnosis
FMHX or FH Family History
PMH Past medical History
CPE or PE Complete physician exam
H&P History and physical
MFH Maternity family history
PFH Paternal family history
Created by: 100001204610760