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Leah WL
Medical Administrative Skills Class
| Question | Answer |
|---|---|
| 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 |