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Bookkeeping
Chapter 36
Question | Answer |
---|---|
Listening attentively is which one of the important interviewing skills | Effective Listening |
One way of being a good listener is to hear, think about and respond to what the patient says is called | Active Listening |
What does it mean to be an active listener | you look at the patient, pay attention and provide feedback |
When you repeat what the patient says, in your own words, back to the patient this technique is called | Restatement |
The patient's tone of voice, facial expression, and body language are examples of | Nonverbal Communication |
What methods of collecting patient data requires more than a yes or no answer but allows the patient to more fully explain the situation | Asking open-ended questions |
What methods of collecting patient data involves restating what the patient says in your own words | Mirroring |
What method of collecting patient data means stating what you believe that patient is suggesting by his response | Verbalizing the implied |
What method of collecting patient data shows the patient that you are really listening to what he is saying | Focusing on patient |
True or False - The patients chart is a legal document and the chart can be used as evidence in a court of law | TRUE!! |
What are the Six C's of Charting | 1. Client's words 2. Clarity 3. Completeness 4. Conciseness 5. Chronological order 6. Confidentiality |
Which one of the Six C's of charting deals with the recording exactly what was said | Client's words |
Which one of the Six C's of charting is essential when you describe the patient's condition, you must use medical terminology and precise descriptions | Clarity |
Which one of the Six C's of charting is required on all the forms used in the patients record | Completeness |
Which one of the Six C's of charting can save time and space when you are recording information | Conciseness |
Which one of the Six C's of charting talks about dates on all entries in the patient's records and are arranged witht he most recent informaion on top | Chronological order |
Which one of the Six C's of charting is essential to protect the patient's privacy | Confidentiality |
What does the acronym SOAP represent | S-subjective O-objective A-assessment P-plan |
Thoughts, feelings, and perceptions including chief complaint are what type of data | Subject data |
In the subjective data, the chief complaint should always be recorded in the patient's ?? | Own words |
Vital signs or test results and the physician's exam are considered what type of date | Objective data |
The physician's diagnosis or impression of the patient's problem is what part of the charting method SOAP | Assessment |
What type of infomation would be listed under PLAN of action in the SOAP method of charting | Options for treatment, they type of treatment chosen, medications, tests, consultations, patient education and follow up |
On the health history form which is abbreviated as CC and is the reason the patient came to visit the practitioner | Chief Complaint |
This part of the health history form includes detailed information about the chief complaint including when the problem started and whe the patient has dont to treat the problem | History of Present Illness |
Which part of the health history form included any and all health problems both present and past including major illnesses and surgery | Past Medical History |
This section includes informaion about the health of the patient's family members | Family History |
What ?'s would be asked about the Social and Occupational History on the health history form | Informaion such as marital status, sexual behaviors and orientation, occupations, hobbies and the use of chemical substances. Alcohol, tabacco, recreational drugs. Occupational: level of stress, exposure to hazardous substances and heavy lifting |
This is a systematic review of each of the body systems and is performed by the physician | Review of Systems |