click below
click below
Normal Size Small Size show me how
MAA 104
FINAL REVIEW
Question | Answer |
---|---|
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 |