chapter 13 medical record
Quiz yourself by thinking what should be in
each of the black spaces below before clicking
on it to display the answer.
Help!
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| What is the purpose of Medical Records | Maintain pt.'s health information
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| A complete & accurate medical record is a combo of: | pt.'s medical history, known family history
pt.'s personal history, pt.'s personal history, social habits, med/allergies,
occupational exposures, test performed.
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| pt.'s personal info includes: | Demographic info, age,
ethnicity, occupation,
insurance info
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| Charting: | a process that lays out a chronological
account of the pt.'s reports, evaluation,
prescribed treatment & need for f/u
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| legal document | medical record that also serves as a
legal document
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| legal document supports | pt.'s account of injury
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| legal document defense | for the provider against legal action
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| chart belongs to.... | the practice
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| all interactions w/ the pt.'s are | documented
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| when documenting use_______ ink | black
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| if errors are made, cross out w/ a | single line through it
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| write correction where? | above or next to it and then initial
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| H.I.P.A.A means | Health, Insurance, Portability,
accountability, Act of 1996
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| H.I.P.A.A maintains the | privacy of pt.'s health info
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| privacy officer duties are.. | to keep track of who has access to PHI
(Protect Health Information)
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| H.I.P.A.A applies to... | medical records, computers,
conversations, financial info
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| pt.'s flies are arranged in... | orderly fashion in sections
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| Progress notes go on what side of record | on the right, w/ labs and physicals
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| demographics go on what side od record | on the left, w/ authorization, forms,
meds list and immunizations
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| when filing the most current info it goes.. | on the top
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| subject data is | info supplied by the pt.
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| chief complaint is | pt.'s own words for the reason for visit
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| objective data is | info obtained by the doctor or MA by exam
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| pt.'s 1st visit must provide | demographic info
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| demographics refers to... | d/o/b, marital status, phone#'s
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| always ask pt. if they have... | allergies and what meds they are on or
have taken
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| step 1 of pt.'s screening | call pt. from waiting room by full name
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| step 2 of pt.'s screening | introduce your name and title
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| step 3 of pt.'s screening | take a seat in chair/exam table
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| step 4 of pt.'s screening | ask pt. for CC
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| how do you help pt. with CC | ask questions.(how long, where, how bad)
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| step 5 of pt.'s screening | ask about meds/allergies
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| once completed step 6 is? | review the cc with pt.
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| step 7 of pt.'s screening | ask if they have questions,
notify when MD will be in
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| Imaging procedures include: | MRI,CT Scan,
x-rays, ultra sound
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| lab info consists of.... | blood work, urinalysis,
pathology/cytology
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| lab results are either | positive or negative
(abnormal) (normal)
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| labs w/ critical values should be... | highlighted, noted, & presented
to the provider
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| meds are documented in the | medication section of the chart
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| complete medication entries include | prescriber, med name, dose,
site, time, observation period,
pt.'s response to meds
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| copies of RX are also placed in | the chart
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| P.O.M.R stands for | Problem
Oriented
Medical
Record
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| P.O.M.R organized according to the pt.'s | health problems
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| S.O.A.P stands for | subjective
objective
assessment
plan
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| H.P.I.P | history
physical
impression
plan
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| C.H.E.D.D.A.R | chief complaint
history
examination
details
drugs & dosage
assessment
return
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| filling medical steps | Inspection, Indexing, Coding,
Sorting, Storing
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| filling systems | alphabetic, numerical,
Chronolgical
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| Tickler file | f/u method for a particular date.
can be expanding file.
offices have pt. fill out a card as a reminder.
tickler must be check every day.
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| purging means to | cleaning out.
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| HIPPA requires all medical records be kept for | 6 years
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| records of the deceased are kept for... | 2 years
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