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Medical Administrative Skills

What is Source-Oriented Medical Record (SOMR) Similar information is kept together or information from similar resources is grouped together.
What is Problem-Oriented Medical Record (POMR) Involves grouping together all the information related to each problem.
How do you read a terminal digital filing? Right to Left
What are the most common used filing systems? Alphabetical and numerical.
What is one main reason for using color coding? It reduces the number of misfiles that occur in the records room
What can be found in an operative report? Name of procedure performed
What is one necessary skill of a medical transcriptionist? Must have comprehension of anatomy, physiology, pathology, and associated medical terminology.
How do you read consecutive filing? Left to Right
What is SOAP? Subjective, Objective, Assessment and Plan
History and Physical Reports contain? Patients identification, chief complaint, past medical history, physical examination, vital signs and plan.
Discharge Summary is? A synopsis of the patients hospital treatment.
What does not belong in a medical record? Patients billing information.
How is the name entered? Last name, First name and middle initial.
What is one way Medical Records can be released? Photocopy given directly from office
Why is it important that quantitative analysis be done on medical records? Medical record information is needed for insurance claims
What must be signed when a patient wants his records transferred from one health care facility to another? Release of Information
Why is it important to protect the confidentiality of patients electronic health information? Track employee use of the system.
Can you use white correction fluid to correct errors in a paper medical record? No
What is a tickler file? It reminds an assistant of activities that must be completed at a certain time.
Does a patients lawyer have the right to view a patients record without patients permission? No
What is the difference between laboratory reports and pathology reports? The pathology reports is the study of diseases and the laboratory report is the place where the disease is being tested.
Should all employees & volunteers should be required to sign confidentiality agreements Yes
What are examples of Radiologic studies? X-Ray, Magnetic Resonance Imaging (MRI), computed tomography (CT) scan, and nuclear medicine.
Created by: jacgar1224