Medical Admin
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 common method of filing? | Alphabetic
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| What best describes the proper way to index personal names? | (Last name) (First name) (MI)
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| Hyphenated names are considered what? | one unit
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| Put in order: 1)Sr. 2)lll 3)4th 4)11 5)Jr. 6)5th | 1)4th 2)5th 3)ll 4)l 5)Jr. 6)Sr.
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| What is the importance of medical records accuracy? | Critical for smooth functioning and for legal issues.
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| What office tool helps to ensure charts may be tracked down when borrowed? | An Outguide- paper or file that lets someone know where a patients file is and when it will be returned.
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| Rule 3 of filing? | Nothing before something
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| What is indexing? | Placing items in filing order.
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| What is the name of a mark placed on a document after it is determined that no further follow up is needed? Who makes that mark? | Release Mark; Physician or Provider
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| S in SOAP meaning | Subjective- what patients c/c is and symptoms
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| O in SOAP meaning | Objective-signs, what you can see
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| A in SOAP meaning | Assessment- diagnosis
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| P in SOAP meaning | What the physician's plan is to make patient better.
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| Describe in the proper way to correct an error in a chart | Put a single line going thru the word with initial over it.
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| What is the term used for the main reason for a patients visit? | Chief Complaint. c/c
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| Subjective findings are also known as | Symptoms
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| Objective findings are also known as | Signs
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| What is the information an out guide should contain besides the date a chart was removed? | Why is it being removed, Who has removed it, where did it go to, when will it return.
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| Heredity tendencies | Family History (FH)
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| Tends to detect conditions other than those covered in present | Review of Systems
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| Hobbies, interests, methods of exercise | Social History
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| Covers dates and quests regarding previous complaints | Past History
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| Eating, drinking, smoking and sleeping habbits | Social History
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| Typically reason for visit | Chief Complaint
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| Conclusion physician reaches after evaluating all findings | Diagnosis
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| X-rays, Blood work, UA | Laboratory Reports
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| PMHx reports, Physical Exams, Follow-up notes | Clinical notes
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| Outside letters from other physicians, clinical offices | Correspondeneces
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| Insurance related papers, requests for transfer or medical records, anything not related to direct treatment of the patient. | Miscellaneous
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| Release Mark | Used to let staff know an item was signed off and may be filed in the chart.
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| Purging | The method of removing files from the office that are no longer in use.
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| Out guide | A tool used to insure that records are tracked when borrowed.
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| POMR | Method by which problems are identified by the number that corresponds to the problem.
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| ROS | Guide to general health that tends to detect condition other than those covered by present illness
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| Symptom | Perceptible only to patient
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| Cardinal Symptom | Symptom of the greatest significance to the overall condition.
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| SOMR | Groups information in the chart according to category.
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| Signs | Perceptible to another person.
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| Cross Referencing | Card or sheet that may be used when name is indexed in more than one way
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| Hyphenated names are separated into 2 units for filing | False
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| North West is the same as Northwest in filing | False
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| Symbols in company names are spelled out. | True
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| Punctuation is ignored in filing, | True
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| Records are retained for 7 years and certain files put on microfilm before destroying | True
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| MA's do a review of systems before the physician sees the patient | False
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| The last name ST. Mark would be spelled out and indexed as Saint Mark | False
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| CC | Chief Complaint
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| DX | Diagnosis
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| FMHX or FH | Family History
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| PMH | Past medical History
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| CPE or PE | Complete physician exam
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| H&P | History and physical
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| MFH | Maternity family history
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| PFH | Paternal family history
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