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Chapter 11 & 12 (
Question | Answer |
---|---|
Most important duty of a M.A | Accurate patient chart |
Important history about a patient medical history is found in their? | Patient health recorded |
In addition to being essential documents for patient records are used for? | Providing patient education |
Patient illness or reason for visit | Patient medical history |
Purpose why having patient sign confidentiality and patient understand treatment | Informed consent |
Summary of a reason a patient is discharged from a hospital | Discharge summary |
First document found in patient financial record | Patient registration form |
Best way to make sure a practitioner see x-ray | Make sure he initials it. |
Best place to interview a patient | In a private place |
Patient walked 20 feet no signs of SOB - what is this an example of? | Clarity |
Example of a patient sign? | Rash |
External factor | Rash |
Example of a symptom | Pain |
Internal factor | Symptom |
Objective of a external factor that can be seen or felt | Sign |
Type of document that provides an series of steps in dealing with patient medications | SOAP |
What does S stand for? | Subjective |
Who had the right to sign a form for child | Both parents |
Age of consent? | 18 |
Appropriate way to delete medical record | Draw a line |
O stands for? | Objective |
What is it called when you put information into charts? | Documentation |
Access codes in EHR system shows? | Name and time stamp |
EHR systems allow patient to access what? | Portal |
The A stands for? | Assessment |
When is the information such as lab test results available to view? | Immediately |
Who owns the patient health records? | The patient |
P stands for? | Plan |
Percent of US gross national product? | 15% |