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MOM Ch 2, 7, & 10
Side A
| answer | question |
|---|---|
| Verbal communication | communication in spoken word |
| Content, Concise, Clarity, Coherence, Check | 5 Cs of communication |
| do not chew gum or eat food while speaking; be sure to speak loud enough to be heard by the listener; pronounce all words correctly | Guidelines for effective verbal communication |
| active listening | listening as well as observing behaviors during a conversation |
| written out | one to ten should be |
| written in numerical form | numbers larger than ten |
| Ms | marital status unknown or if the woman prefers. Use when in doubt |
| Mrs | married woman |
| Miss | unmarried woman who prefers that title, or for young girls. |
| Proofreading | the process of checking for spelling or content errors within a letter |
| postage meters | used to weigh the mail piece, determine the correct amount of postage required, and print the postage |
| body language | nonverbal communication, such as nodding the head, crossing the arms, & frowning |
| therapeutic touch | use of touch to convey concern & compassion for another |
| therapeutic communication | seeks to elicit some form of response from the patient, typically a calming or soothing approach |
| direct reports | employee who reports directly to a particular manager |
| eye contact & hand shaking | 2 inappropriate gestures while communicating with other cultures |
| medical record | a record of the patient's healthcare |
| personal information | information pertaining to the patient, such as address & telephone number |
| financial information | items in the medical record pertaining to the patient's insurance coverage or account status |
| medical information | information in the patient's medical record pertaining to his medical history or condition |
| social information | information in a patient's chart relating to his social status, such as smoking or participating in high-risk behaviors |
| chief complaint | the main reason the patient sought care today |
| Concise, Complete, Clear, Correct, Chronologic | 5 Cs of medical records |
| Concise | containing only the necessary information |
| Complete | all necessary information |
| Clear | to the point & easily understood |
| Correct | accurate |
| Chronologic | the order in which events occur in time, from oldest to newest |
| Subpoena | a court order received by the medical office for all or a portion of a patient's medical record |
| standard of care | the care that is expected from a clinician with a certain level of training & resources available |
| electronic signature | an electronic version of a person's signature |
| narrative chart note | written descriptions of patient's visits; the oldest form of medical note taking |
| SOAP note charting | subjective, objective, assessment, & plan; a common form of charting in the medical record where clinicians chart information in an easy-to-find format |
| problem-oriented medical record (POMR) charting | a charting process that allows providers to assign a number to each medical problem & chart each item each time the patient is seen for care |
| flowchart | chart used in the medical record to chart the progress of growth, such as child height, weight, & head circumference |
| progress notes | the daily chart notes taken all the time of a patient's visit to a clinic |
| shingling | the process of taping small pieces of paper to a full size sheet of paper so that small items are not lost in the chart |
| cross-referencing | a process for locating files when a patient may go by one or more last names |
| statute of limitations | the period of time provided by law for a patient to file a malpractice lawsuit from the date of the injury |
| discovery rule | relates to when an injury was discovered, rather than when the injury occurred |
| active patient file | medical record for a patient who is actively treated in the medical office |
| inactive patient file | patient file or a patient who has not been seen in a certain period of time, but who will likely return one day |
| closed patient file | medical record for a patient who has moved out of the area, is deceased, or has indicated that he will not be returning for care |
| purge | to go through files & remove the items or charts that are old or no longer needed |
| obliterated | completely marked out so that the original is unrecognizable |
| the physician or facilities where they are created | medical records belong to |
| the patient | the information inside a medical record belongs to |
| access their medical records & to correct those records when they feel errors have been made | patients have the right to |
| indecipherable | unreadable |
| advance directive | a legal document that outlines a patient's desire regarding life-sustaining treatments or names a guardian to speak for the patient |
| medical research program | medical program geared toward researching a particular condition or treatment |
| nontherapeutic research | medical research that does not have therapeutic value to the patient |
| hardware | the equipment itself; including the hard drive, monitor and keyboard |
| software | programs in the system |
| peripherals | extras that can attach to ro be installed in the hardware, such as scanner or printer |
| central processing unit (CPU) | the microchip inside the computer that processes the software programs commands |
| ergonomic | designed to promote good posture & limit physical injuries |
| medical management software | computer software used in the medical office to assist in task such as billing, coding, & payroll |
| hackers | person who illegally obtain access to a computer network |
| computer viruses | program designed to perform mischievous functions |
| malware | software designed to destroy portions of a computer; more malicious that a computer virus |
| Internet search engines | sites on the Internet used for locating needed information |
| health-related calculators | Internet sites that provide calculators for determining pregnancy due dates, body mass index, & other numbers |
| scanners | similar to photocopies; copy documents & place in file |
| bar code reader | identifies patient file or patient data;maintain inventory or supplies |
| prescription management software | cannot prescribe controlled substances |
Created by:
Stacey_Gantt5
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