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Leah WL

Medical Administrative Skills Class

Electronic Health Record same type of patient information that is digitally stored.
Summary Sheet identification sheet or face sheet
Progress Notes information regarding the patients visits to the health care provider
SOAP method one of the most common methods of documenting patient visits in a chart note
SOAP subjective, objective, assessment, and plan
chief complaint primary reason for seeing the physician
objective physical examination to investigate the chief complaint
assessment diagnosis, impression,________
plan treatment recommended for patient
pathology report contains descriptions of body tissue that has been sent to a medical lab for study
discharge summary synopsis of patients hospital treatment
outguide used to hold a place of a record
accession ledger used to keep track of each number as it is assigned to a patient
How are terminal digits read? from right to left
consecutive number filing arranged in ascending number order, from the lowest number to the highest number
Which of the following does not belong? a. chief complaint b. diagnosis c. impression d. assessment
Types of filing in the office Numerical , alphabetical, and color coding
When terminal digit filing is used, which number would be filed first? a. 98-48-35 b. 04-85-32 c. 6- 48-53 d. 1-22-33
What is used as reminders for staff? Tickler file
Records of patients who are currently undergoing or have recently undergone treatment? Active Records
Created by: lwlleah23