FINAL REVIEW
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 a symptom felt by the patient, but not observed by an examiner? | Subjective symptom.
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| What are conclusions drawn by the physician from an interpretation of data? | Medical Impression
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| What is an objective symptom? | One that can be observed or measured by an examiner
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| What is prognosis? | The probably course and outcome of a patient's condition
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| What is a report of the physician's objective findings? | Physical Exam Report
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| What is a collection of subjective and objective datat about a patient? | Health history report
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| What is chorological Order? | Place in order of time; usually the most recent is placed foremost
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| What is the chief complaint? | Mand readon for the visit to the medical office. In the patient's own words
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| Describe a narrative: | A paragraph indicating the contact with the patient, what was done for the patient, and the outcome of any action
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| What is a referral? | Instructions to transfer a patient's care to a specialist
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| What is a diagnosis? | A disease or condition indentified in a person
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| Describe demographic data: | Information necessary for administrative purposes i.e. Name, Address, Phone Number, Marital Status, Gender, Race
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| Describe POMR | Problem Oriented Medical Record: A common method of compiling information that lists each problem at the beginning of the chart, giving it a number and referring to that problem by number throughout the chart
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| List ways to maintain security of information: | Train all employees on confidentiality and HIPAA Conduct routine audits of movement through records Prepare a back-up plan for when the system is down
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| A patient complains of a headache for the last two days. This is part of which part of SOAP charting? | Part of the subjective patient information
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| Why should you keep medical records? | Used in malpractice suits. They evaluate the quality of treatment. Provide continuity of care. Legal document. Can be subpoenaed.
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| Which title of HIPAA covers health insurance access, portability and renewal? | Title 1
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| True/False: HIPAA requires that each office designate at least one employee to oversee and coordinate various aspects of compliance | True
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| How do you document an event after the actual time that it happened? | Document with today's date, but chart late entry for the date and time it actually happened
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| What are covered entities? | Health Insurance Companies, Clearinghouses. Under HIPAA it is all who must adhere to their regulations.
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| What are 4 component parts of a POMR chart? | Database, Problem List, Treatment Plan, Progress Notes
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| What are flow sheets? | Record of ongoing measurements in a graph or chart form.
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| Abbreviations used in medical records should be: | Accepted for use by the facility for office. Standard Medical Abbr.
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| Is it ok to release medical imformation over the phone? | No
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| Should correction fulid be used in medical records? | No
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| What is the Golden Rule of documentation? | If it isn't documented, it didn't happen.
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| The physical record belongs to who? | The physician (Or clinic if ti's a group practice)
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| When is the only time the original record should be released? | When subpoenaed by a court of law
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| Release of patient Information | Cannot be given over the phone Should not be transmitted with SSL or encryption
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| How to correct a medical record entry | Draw a single line through the error, make correction, sign and date it
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| Chart Status: | Active: Patients currently being seen on a regular basis Inactive: Patients who have not been seen recently Closed: Deceased patient or those who have moved or dismissed
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| Protection of files: | Back-up regularly (nightly) Store back-ups off premises Do not open email from epople you don't know
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| AMA recommedation: | Set security levels to limit entry to all functions Store disks in a bank safe-deposit box Prepare a back-up plan if system is down
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| SOAP Charting | Subjective: What the patient tells you Objective: What you can see, measure Assessment: Diagnosis Plan: for treatment
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| Progness Notes | Documentation of each patient encounter, inlcluding phone calls and prescription refills
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| Advance Directive | Instructions regarding end of life decisions
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| HIPAA TITLE 1: | Covers health insurance access, portability and renewal. Those who must fall the rules: Covered Entities HIPAA officer: Oversees and coordinates all aspects of compliance
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