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MOPS 1
Terms and Patient Record
| Question | Answer |
|---|---|
| What is the diference between medical record and medical report. | Report - One sheet stating result of exam. Record - complete set of patient information. |
| Determination of a disease | Diagnosis |
| The study of the causes of a disease. | Etiology |
| Forcast of the outcome of a illness. | Prognosis |
| A sign is what kind of information | objective |
| A symptom is what kind of information | Subjective |
| What does SOAP stand for? | Subjective, Objective, Assessment and Plan |
| What do you do first to correct an error? | Put a single through the mistake |
| What do you do second to correct an error? | Write 'error' above mistake |
| What do you do third to correct an error? | Near error you write the date including the year and your intitnals. |
| What is the last step to correcting a mistake? | Write the correct information |
| List three benefits of shingling | 1 - saves space 2 - Prevents loss of records 3- allows for the most recent report to be readily available |
| Te SOAP approach of writing progress notes is known as what method of record keeping | Traditional |
| How should reports be placed in a patient's chart | Reverse chronogical order |
| First item medical records are used for | Patient education |
| Second item medical records are used for | Research |
| Third item medical records are used for | Evaluate |
| What does congenital mean | Birth defect |
| Are congenital defects subjective or objective | They can be both |
| What is a pocket Call Record | Doctor carries to out of office visit |
| Is the condition of a patient at the time of termination of treatment objective or subjective | objective |
| Should a doctor chart the condition of a patient when treatment is terminated | Yes |
| What should happen before any transcribed notes or lab reports are placed in patients medical record? | Doctor should intitial |
| What does POMR stand for | Problem Oriented Medical Record |
| Define percussion | Tapping done with fingers for sounds |
| Define inspection | Exam with eyes |
| Define Palpation | Exam by feeling |
| Define Auscultation | Listening to sounds with stethoscope |
| Is there a different in how you correct handwritten or typewritten errors | No |
| To show a mutual relationship | correlation |
| Determation of the nature / cause of a disease | Diagnosis |
| To see or understand a difference between two things | Discernible |
| Being an indispensable part of a whole | Integral |
| complete set of patient information | Medical record |
| Results of an exam | Medical Report |
| Define objective | Perceptible to the observer |
| An inference from what has been seen or heard | Observation |
| Competency as a result of training & experience | Proficiency |
| Records of patient visits, phone calls, progress & treatment that are inserted into the patients chart | Progress notes |
| objective evidence of disease discoverable by dr. | Sign |
| Fings perceptible only by the effected person | Subjective |
| Any perceptible change in the body or its functions | Symptom |
Created by:
spawmary
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