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MOM Ch 2, 7, & 10

Side A

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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