Save
Upgrade to remove ads
Busy. Please wait.
Log in with Clever
or
show password
Forgot Password?
Don't have an account?  Sign up 
Sign up using Clever
or
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. Your email address is only used to allow you to reset your password. See 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.
focusNode
Didn't know it?
click below
 
Knew it?
click below
Don't Know
Remaining cards (0)
Know
0:00
edit
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

Chapter 8&9 - Howell

QuestionAnswer
PC Present complaint
PX Physical examination
HEENT Head, eyes, ears, nose & throat
PI Present illness
TPR Temperature, pulse, respiration
Neg. Negative
CV Cardiovascular
GI Gastrointestinal
RUQ Right upper quadrant
Abdom Abdominal
GU Genitourinary
GYN Gynecology
Dx Diagnoses
GB Gallbladder
Why is it important for all members of the office staff to follow a general office filing system and obey filing rules Medical records constitute the collective memory of a physician's practice
When choosing a medical filing system, what must be considered Number of active records Number of inactive records Frequency of record retrieval Amount of filing space Convenience of file locations Cost of the system
Name three advantages of using an alphabetical color-coded file system Reduces misfiles Speeding retrieval Makes office filing more efficient
Name several types of information that may be filed in a subject file Diagnoses Treatment Prognosis Additional information outlined
In a chronological filing system, numbers are used based on Dates
A person's name is also called the Given name
The last name is the Surname
A married woman may legally write her name three different ways, give 3 examples Her first name and middle name with husband's surname Her first name and maiden name with her husband's surname Her first name and her surname
CC Chief complaint
BM Bowel movement
CPX Complete physical exam
Int Internal
Ext External
BP Blood pressure
Cm Centimeter
Rx Prescription/treatment ordered
Adv Advice
Dg Diagnoses
HBP High blood pressure
5 reasons for keeping medical records Aid in diagnosis and treatment of pt Provide written documentation of directed pt care To ensure continuity of care Verify services were medical necessary Comply with federal and state laws
List some of the disadvantages of a paper-based medical record system Time consuming to maintain More vulnerable to a variety of security threats No easy way to search for clinical data Costly to manage Costly to move Costly to store
What equipment is necessary to digitalize medical records when converting from a paper-based system to an electronic-based system Scanner
Attending physician Medical staff member who is legally responsible for care of pt
Consulting physician Provider whose opinion is requested
Ordering physician Provider directing selection, preparation, or administration of tests, medication, or treatment
Referring physician Provider who sends the pt for testing
Treating or performing physician Provider who renders service to pt
S Subjective - statements about how pt feels
O Objective- data from physician's findings
A Assessment- analysis of S+O portions of chart
P Plan- therapeutic treatment plan and instructions to pt by physician
Using documentation guidelines, what is said about abbreviations Appear in chart notes-physician's document quickly
List 4 basic elements of a pt history CC HPI PFSH ROS
POMR Problem oriented medical record system- tracks specific data
SOR Source oriented record system- most common, organized by sections
SOAP Subjective, objective, assessment, plan
CHEDDAR Chief complaint, history, exam, details, drugs, assessment, return visit
NCAT Normal head no trauma
MMM Mucous membrane moist
EOMI Extraocular muscles intact
PERRLA Pupils extract, round and reactive to light and accommodation
PF Problem focused- limited exam of the effected body area
EPF Expanded problem focused- limited exam of the affected body area or organ system and other symptomatic or related areas
D Detailed- extended detailed exam of the affected area
C Comprehensive- a general multi system exam or complete exam of a single organ system
SF Straight forward
LC Low complexity
MC Moderate complexity
HC High complexity
Risk Complications
Diagnosis Impression, assessment, final conclusion
Treatment Treatment for diagnosis Recommended plan of care
Prognosis Probable outcome Prospect of recovery
POL Physician's office lab
Documents are arranged according to SOR system
Documented of the medical record Are all individuals who provide health care services
Difference between electronic signature and digital signature Digital is a serious of letters or numbers that cannot be altered and an electronic is a facsimile of a persons actual handwriting
HPI is Chronological description of the development of the pt's present illness
During a physical exam, in what order is the body examined Examined from head to toe
The complexity of medicinal decision making is dependent on which three items 1- number of diagnoses and management options 2- amount and complexity of data to be reviewed 3- risk of complications, morbidity, and comorbidities or mortality
Prospective review A type of internal review where medical staff look at medical records to verify that good recordkeeping is in place and that documentation is valid before billing, it will be submitted for a
When selecting a filing system, determine two things to consider Security and expansion
A subject filing system is usually used for Business records
In an indirect filing system, you begin to look for a file by Going into cross reference table
A tickler file system is also called Suspense file
Most popular file cabinets Lateral
The "cut" of a file folder describes the Number and position of tabs
A record retention schedule is List of record types and length of time each should be kept
What organization developed the rule for alphabetical filing that are still used today ARMA
Created by: KirstinParise
 

 



Voices

Use these flashcards to help memorize information. Look at the large card and try to recall what is on the other side. Then click the card to flip it. If you knew the answer, click the green Know box. Otherwise, click the red Don't know box.

When you've placed seven or more cards in the Don't know box, click "retry" to try those cards again.

If you've accidentally put the card in the wrong box, just click on the card to take it out of the box.

You can also use your keyboard to move the cards as follows:

If you are logged in to your account, this website will remember which cards you know and don't know so that they are in the same box the next time you log in.

When you need a break, try one of the other activities listed below the flashcards like Matching, Snowman, or Hungry Bug. Although it may feel like you're playing a game, your brain is still making more connections with the information to help you out.

To see how well you know the information, try the Quiz or Test activity.

Pass complete!
"Know" box contains:
Time elapsed:
Retries:
restart all cards