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JGarcia
Medical Administrative Skills
Question | Answer |
---|---|
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. |