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101 Terms
What is a health history?
A collection of data obtained by interviewing a patient or having the patient complete a preprinted form
Who reviews the health history for completeness?
The medical assistant (MA)
When is a thorough health history taken?
On a new patient
What information is obtained during subsequent visits?
Changes in the patient’s illness or treatment
What are notes documenting changes in illness or treatment called?
Progress notes
What type of environment encourages a patient to communicate during a health history?
A quiet, comfortable room
What effect does showing interest and concern have on a patient?
It reduces patient apprehension
What does reducing patient apprehension help with during a health history?
Facilitates collection of data
What is an EHR health history?
A health history recorded in the electronic health record (EHR)
How may a patient initially complete a health history for the EHR?
By completing a paper/pencil health history
What does the medical assistant do with a paper/pencil health history?
Enters the data into the computer
What is one alternative way to complete an EHR health history?
The MA asks the patient questions related to health status and enters the information directly into the computer
What is another alternative method for completing an EHR health history?
The patient completes the health history on a computer using a computer-guided questionnaire
When is a health history taken in relation to the physical examination (PE)?
Before the physical examination (PE)
What is included in the identification data section of the health history?
What section of the health history describes the patient’s main reason for the visit?
Which health history section describes the patient’s current condition?
Which section of the health history includes allergies, current medications, and immunizations?
Which section of the health history includes the patient’s previous illnesses and conditions?
Which section of the health history includes medical conditions of relatives?
Which section of the health history includes lifestyle and social factors?
Which section of the health history reviews body systems?
Identification data
Chief complaint
Present illness
Allergies, current medications, and immunizations
: Past history
Family history
Social history
Review of systems
Where is identification data included on a paper health history form?
At the beginning of the paper health history form
What type of information does identification data contain?
Basic demographic data
Who completes the identification data section of the health history?
The patient
What happens to identification data when an office uses an EHR?
Selecting the correct patient automatically links history information to patient demographic data
What is the chief complaint (CC)?
What does the chief complaint usually describe?
The patient’s reason for seeking care
The symptom causing the patient the most trouble
What is the chief complaint the foundation for?
The present illness and the review of systems
Who is usually responsible for obtaining and recording the chief complaint?
The medical assistant (MA)
How is the chief complaint recorded?
On a preprinted lined form
What type of questions should be used when obtaining the chief complaint (CC)?
What is an example of an open-ended question used to obtain the chief complaint?
Open-ended questions
What seems to be the problem?”
How many symptoms should the chief complaint be limited to?
One or two symptoms
How should the chief complaint describe symptoms?
It should refer to a specific symptom rather than a vague symptom
How should the chief complaint be recorded?
Concisely and briefly, using the patient’s own words as much as possible
What additional detail should be included when recording the chief complaint?
The duration of the symptom
What should NOT be used when recording the chief complaint?
Names of diseases or diagnostic termsTechnical jargon or abbreviations
What is an example of a correctly written chief complaint?
Burning during urination that has lasted for 2 days
Why is “burning during urination that has lasted for 2 days” a correct chief complaint?
It identifies a specific symptom and includes the duration
What is an example of an incorrectly written chief complaint?
Ear pain and fever
Why is “ear pain and fever” an incorrect chief complaint?
The duration of the symptom is not listed
What is the present illness?
An expansion of the chief complaint (CC)
What does the present illness describe?
A full description of the patient’s current illness from the time of onset
Who often completes the present illness section?
The medical assistant (MA)
How does the MA obtain information for the present illness?
On what form is the present illness recorded?
By asking the patient questions
On the same form as the chief complaint
Why does documenting the present illness require skill and practice?
It requires asking proper questions to obtain a detailed description of the CC
What does the past history section describe?
The past medical status of the patient
Why is past history important in patient care?
It assists the physician in providing optimal care
Who completes the past history section?
The patient
What format is commonly used for documenting past history?
A checklist form
What is the medical assistant’s role in the past history section?
The MA should assist the patient if needed
What information is included in a patient’s past history?
Major illnesses and/or previous health problems
Does past history include information about hospital stays?
Yes, hospitalization is included
Are operations part of the past history section?
Yes, operations are included
Are previous surgeries documented in the past history section?
Yes, previous surgeries are included
What is the purpose of the family history section?
To review the health status of the patient’s blood relatives
Which relatives are included in family history?
What is the main focus of the family history section?
: Blood relatives
Familial diseases
What is a familial disease?
A disease that occurs in blood relatives more frequently than would be expected by chance
Why is family history important in patient care?
It helps identify diseases that may have a genetic or familial pattern
What four conditions are listed as examples in family history?
Hypertension, heart disease, allergies, diabetes mellitus
Who completes the family history section?
The family history includes information on whom?
The patient
Each blood relative
What health-related detail is included for each blood relative in the family history?
What disease-related information is included for each blood relative?
What information is included if a blood relative is deceased?
State of health
Presence of any significant disease
Cause of death
What type of information is included in the social history?
What is the purpose of collecting a patient’s social history?
What may be recommended if a major lifestyle adjustment is necessary?
What is an example of a major lifestyle adjustment mentioned in the social history?
Who completes the social history section?
Information on the patient’s lifestyle, including health habits and living environment
Lifestyle may have an impact on the patient’s condition
Support services
Smoking cessation
The patient
What does ROS stand for?
What is the Review of Symptoms (ROS)?
What is the purpose of the Review of Symptoms (ROS)?
Who completes the Review of Symptoms (ROS)?
How does the physician complete the Review of Symptoms (ROS)?
How does the Review of Symptoms (ROS) assist the physician?
Review of Symptoms
A systematic review of each body system
To detect any symptoms that have not yet been revealed
The physician
By asking a series of detailed and direct questions related to each body system
It assists in determining the type and extent of physical examination required
What patient identifiers should be checked before documentation?
Where should the patient’s name and date of birth be checked?
Name and date of birth
On the EHR or paper chart
How should information be documented?
What type of phrases should be used when documenting?
Accurately and in a logical order
Clear and concise phrases
What is an important spelling guideline for documentation?
Spell correctly
: When should documentation be completed after a procedure?
Should procedures ever be documented in advance?
Immediately after performing a procedure
No, procedures should never be documented in advance
What is charting?
The process of making written entries about a patient in the medical record
Who performs charting?
Personnel directly involved with the health care of the patient
Why is the medical record considered a legal document?
Because it is important to chart information completely and accurately
What must be checked on the chart before making an entry?
What may happen if documentation is entered in the wrong chart?
From a legal standpoint, what does it mean if a procedure is not documented?
The patient’s name
The procedure may be excluded from the correct patient’s record
The procedure was not performed
What color ink should be used when documenting in a paper-based medical record?
Why should black ink be used for documentation?
Why is black ink easier to reproduce?
How should documentation be written?
Black ink
It provides a permanent record
It allows reproduction of information needed by insurance companies or for patient referrals
Legibly
How should information be charted in a paper-based medical record?
How detailed should charting be?
What should be avoided when charting information?
Is it necessary to include the patient’s name in each entry?
Why does the entry not need to include the patient’s name?
What is assumed about the information in the record?
Accurately using clear and concise phrases
Brief but complete
Vagueness and duplication of information
No
The entire record centers on one patient
It refers to that patient
How should chart information be written?
How should each phrase begin and end?
How should each new entry be started?
What must be included on all entries
Accurately using clear and concise phrases
: Begin with a capital letter and end with a period
On a separate line
Date and time
What types of terms and symbols should be used?
What should be done before using terms in the office?
What should be done to ensure correct spelling?
Standard abbreviations, medical terms, and symbols
First check office policy
Use a dictionary if necessary
When should charting be done after a procedure?
What may happen if charting is delayed?
Should procedures ever be charted in advance?
Who should chart the procedure?
Should you chart for someone else?
Who must sign each entry?
What must be included with the signature?
Immediately after performing a procedure
Certain aspects of the procedure may not be remembered
No
The individual performing the procedure
No
The person making it
First initial, full last name, and credentials
Should an entry ever be erased or obliterated?
Why should entries never be erased or obliterated?
How should an error be corrected?
No
It reduces credibility if involved in litigation
Draw a single line through the incorrect information
What should be written near the correction?
What identifying information must be included when correcting an error?
Where should the correct information be placed?
“Error”
Date, first initial, last name, and credentials
: Next to the errorCorrected information.
When are progress notes updated?
What do progress notes document?
What is one purpose of progress notes?
Why are progress notes important legally?
What type of forms are often used for progress notes?
What are preprinted lined sheets also known as?
Each time the patient visits the office
Patient’s health status, care, and treatment
Provides communication among office personnel
They serve as a legal document
Preprinted lined sheets
Progress note sheets
What is a symptom?
What is a subjective symptom?
What is an objective symptom?
Any change in the body or its functioning that indicates the presence of disease
A symptom that is felt by the patient but not observable by another person (pain, pruritus, vertigo, nausea)
A symptom that can be observed by another person (rash, coughing, cyanosis)
What does taking patient symptoms consist of?
What is also obtained when taking patient symptoms?
Obtaining the CC
Additional information about the CC
What symptoms are associated with the integumentary system?
Diaphoresis,(sweat) flushing, jaundice(yellow skin), rash
What symptoms are associated with the circulatory system?
Bradycardia, dehydration, tachycardia
What symptoms are associated with the gastrointestinal system?
Anorexia, constipation, diarrhea, flatulence, nausea and vomiting
What symptoms are associated with the respiratory system?
Cough, cyanosis, dyspnea, epistaxis
What symptoms are associated with the nervous system?
Chills, convulsions, fever or pyrexia, headache, malaise, numbness, pruritus, vertigo
What activity must be documented related to medications?
Administration of medication
Who is accountable for medication administration documentation?
Personnel with responsibility
What information must be included when documenting medication administration?
Date, name of medication, dosage given, route of administration, initials, any significant observations or patient reactions
What procedures must be documented?
All procedures performed on the patient (e.g., vital signs)
What information must be included when documenting procedures?
Date, time, type of procedure, patient reaction
What activity related to specimens must be documented?
Specimen collection
What information must be included when documenting specimen collection?
Time of collection, date, area of body where specimen was obtained
What additional details must be documented if a specimen is sent to a laboratory?
What should be documented if test results are not back yet?
Tests requested, date specimen sent, where sent
That data are not yet available
What diagnostic activities need to be documented?
Diagnostic procedures and laboratory tests
What information must be included when documenting diagnostic procedures or tests?
Date, time, type of procedure/test(s) ordered, scheduling date, where procedure/test(s) are being performed
What is one purpose of charting diagnostic procedures?
Provides proof that the test was ordered if the patient does not undergo the test
Why does charting diagnostic procedures help the physician?
Refreshes the physician’s memory that tests were ordered if results are not yet back from the laboratory
How may STAT tests or critical findings be reported?
Telephoned
What must be done with telephoned laboratory results?
Recorded on a report form
What laboratory tests must be charted?
What information must be included when charting lab tests performed in the office?
Laboratory tests performed in the office
Date, time, name of test, test results
What type of information may need to be relayed to patients?
Why is it important to chart patient instructions?
What information must be included when documenting patient instructions?
Instructions regarding medical care (e.g., wound care)
To document information relayed to the patient
Date, time, type of instructions relayed to the patient
What may be used to document patient instructions?
What does the patient do to acknowledge understanding of instructions?
Who witnesses the patient’s signature?
Where is the signed instruction sheet kept?
How does the instruction sheet protect the physician?
A preprinted instruction sheet
Signs the form
The medical assistant (MA)
: Filed in the chart; a copy is given to the patient
Legally protects the physician if the patient does not follow instructions and causes harm to a body part
What patient-related activities must be documented?
Patient instructions
What appointment-related events must be documented?
Missed or canceled appointments
What type of patient communication must be documented?
Telephone calls from patients
What medication-related actions must be documented?
Medication refills