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Chapter 11 & 12 (

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%
Created by: Littles_789