Help
Options
Didn't know it?
click below
click below
Knew it?
click below
click below
Don't Know
Remaining cards (0)
Know
retry
shuffle
restart
0:00
Embed Code - If you would like this activity on your web page, copy the script below and paste it into your web page.
Normal Size Small Size show me how
Normal Size Small Size show me how
MAA 104
Final Review
| 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
Popular Medical sets