Busy. Please wait.

show password
Forgot Password?

Don't have an account?  Sign up 

Username is available taken
show password


Make sure to remember your password. If you forget it there is no way for StudyStack to send you a reset link. You would need to create a new account.
We do not share your email address with others. It is only used to allow you to reset your password. For details read our Privacy Policy and Terms of Service.

Already a StudyStack user? Log In

Reset Password
Enter the associated with your account, and we'll email you a link to reset your password.
Don't know
remaining cards
To flip the current card, click it or press the Spacebar key.  To move the current card to one of the three colored boxes, click on the box.  You may also press the UP ARROW key to move the card to the "Know" box, the DOWN ARROW key to move the card to the "Don't know" box, or the RIGHT ARROW key to move the card to the Remaining box.  You may also click on the card displayed in any of the three boxes to bring that card back to the center.

Pass complete!

"Know" box contains:
Time elapsed:
restart all cards
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

Clinical Chapter 1

The Medical Record

Functions of a Medical Record - documents the results of treatment and the patient's progress - serves as a legal document - efficient and effective method for communicating in the medical office
What does HIPAA stand for? What is its purpose? Health Insurance Portability and Accountability Act -To provide patients with a better control over the use and disclosure of their health information.
General categories of information that are included on a patient registration record - Patient's demographic - Billing information
Uses of the health history - To determine the patient's general state of health - To arrive at a diagnosis and to prescribe treatment - To document any changes in a patient's state of health
Categories of medication that may be included in a medication record - Prescription medications - Over the counter medications - Medications administered at the Medical Office
Components of a Medical Record - Administrative/clinical documents - Laboratory - Diagnostic procedures - Therapeutic services - Hospital documents - Consent documents
Administrative Documents - Registration forms - Correspondence
Clinical Documents - Health history - Physical examination - Progress notes - Medication and immunization records - Consultation/home health reports
Laboratory Documents - Hematology - Chemistry - Serology - Urinalysis - Microbiology - Cytology - Parasiology
Diagnostic Procedures - Holter monitor reports - Sigmoidoscopy - Colonoscopy - Spirometry - Imaging (x-rays, CT scans, MRI) - EKG's
Therapeutic Services - Physical therapy - Occupational therapy - Speech therapy
Hospital Documents - History and physical - Operative report - Discharge Summary - Pathology report - ER report
Consent Documents - Consent to treatment - Consent to release medical reports
Medical Record preparation (supplies) - File folders - Labels - Chart dividers
Charting (progress notes) - What do we chart? - Patient symptoms - Procedures - Administration of medications - Specimen collection - Results of lab tests - Diagnostic procedures - Instructions given to a patient regarding care
Created by: Rachel_m