Medical Administrative Skills
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| What is Source-Oriented Medical Record (SOMR) | Similar information is kept together or information from similar resources is grouped together.
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| What is Problem-Oriented Medical Record (POMR) | Involves grouping together all the information related to each problem.
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| How do you read a terminal digital filing? | Right to Left
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| What are the most common used filing systems? | Alphabetical and numerical.
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| What is one main reason for using color coding? | It reduces the number of misfiles that occur in the records room
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| What can be found in an operative report? | Name of procedure performed
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| What is one necessary skill of a medical transcriptionist? | Must have comprehension of anatomy, physiology, pathology, and associated medical terminology.
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| How do you read consecutive filing? | Left to Right
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| What is SOAP? | Subjective, Objective, Assessment and Plan
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| History and Physical Reports contain? | Patients identification, chief complaint, past medical history, physical examination, vital signs and plan.
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| Discharge Summary is? | A synopsis of the patients hospital treatment.
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| What does not belong in a medical record? | Patients billing information.
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| How is the name entered? | Last name, First name and middle initial.
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| What is one way Medical Records can be released? | Photocopy given directly from office
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| Why is it important that quantitative analysis be done on medical records? | Medical record information is needed for insurance claims
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| What must be signed when a patient wants his records transferred from one health care facility to another? | Release of Information
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| Why is it important to protect the confidentiality of patients electronic health information? | Track employee use of the system.
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| Can you use white correction fluid to correct errors in a paper medical record? | No
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| What is a tickler file? | It reminds an assistant of activities that must be completed at a certain time.
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| Does a patients lawyer have the right to view a patients record without patients permission? | No
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| What is the difference between laboratory reports and pathology reports? | The pathology reports is the study of diseases and the laboratory report is the place where the disease is being tested.
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| Should all employees & volunteers should be required to sign confidentiality agreements | Yes
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| What are examples of Radiologic studies? | X-Ray, Magnetic Resonance Imaging (MRI), computed tomography (CT) scan, and nuclear medicine.
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