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CHAPTER 38-43
WHAT INFORMATION IS CONTAINED IN THE MEDICAL RECORD?
HEALTH HISTORY, RESULT OF THE PHYSICAL EXAMINATION, LABORATORY REPORTS, & PROGRESS NOTES
WHAT IS NOT A FUNCTION OF THE MEDICAL RECORD?
TO SERVE AS A LEGAL DOCUMENT
THE PURPOSE OF HIPAA IS TO
PROVIDE PATIENTS WITH MORE CONTROL OVER THE USE AND DISCLOSURE OF THEIR HEALTH INFORMATION
WHAT IS INCLUDED ON A MEDICATION RECORD FOR MEDICATION ADMINISTERED AT THE OFFICE?
NAME OF THE MEDICATION, ROUTE OF ADMINISTRATION, DOSAGE ADMINISTERED & NUMBER OF REFILLS
WHAT ARE SOME EXAMPLES OF A DIAGNOSTIC REPORT
SPIROMETRY REPORT, COLONOSCOPY REPORT, & RADIOLOGY REPORT
WHAT ARE SOME EXAMPLES OF PHYSICAL THERAPY?
ELECTRICAL STIMULATION, HYDROTHERAPY, AND BREATHING TREATMENTS
WHAT IS USED TO DESCRIBE A PATIENT EHO HAS BEEN ADMITTED TO THE HOSPITAL FOR AT LEAST ONE OVERNIGHT STAY?
INPATIENT
THE ACRONYM FOR THE FORMAT USED TO ORGANIZE “POR” PROGRESS NOTES IS
SOAP
DATA OBTAINED FROM THE PATIENT ARE RECORDED IN “POR” PROGRESS NOTES UNDER
SUBJECTIVE DATA
WHAT IS THE CHIEF COMPLAINT?
THE SYMPTOM CAUSING THE PATIENT THE MOST TROUBLE
WHAT IS AN EXAMPLE OF A FAMILIAL DISEASE?
DIABETES MELLITUS
WHAT ARE SOME EXAMPLES THAT ARE INCLUDED IN THE SOCIAL HISTORY?
DIETARY HISTORY, PNEUMONIA, AND TUBERCULOSIS
BLACK INK SHOULD BE USED WHEN RECORDING IN THE PATIENTS CHARTS TO
REDUCE CHARTING ERRORS
THE PURPOSE OF PROGRESS NOTES IS TO
UPDATE THE MEDICAL RECORD WITH NEW PATIENT INFORMATION
WHAT IS A SYMPTOM?
ANY CHANGE IN THE BODY OR ITS FUNCTIONING THAT INDICATES DISEASE
FLUSHED SKIN USUALLY INDICATES
AN ELEVATED TEMPERATURE
A YELLOW COLOR OF THE SKIN THAT IS FIRST OBSERVED IN THE WHITES OF THE EYE IS CALLED
JAUNDICE
A DECREASE IN THE AMOUNT OF WATER IN THE BODY IS KNOWN AS
DEHYDRATION
WHAT IS USED TO DESCRIBE EXCESSIVE PERSPIRATION?
DIAPHORESIS
WHAT IS USED TO DESCRIBE DIZZINESS?
VERTIGO
WHAT IS THE NAME FOR THE STATEMENT THAT ALLOWS THE OFFICE TO RELEASE INFORMATION TO THE INSURANCE COMPANY FOR BILLING PURPOSES?
RELEASE INFORMATION FORM
WHAT ARE SOME ADVANTAGES OF USING A COMPUTER?
TASK CAN BE PERFORMED WITH GREATER ACCURACY, TASK CAN BE PERFORMED WITH GREATER SPEED, A VARIETY OF DIFFERENT TASK CAN BE PERFORMED, & TASK CAN BE PREFORMED REPEATEDLY WHILE MAINTAINING THE SAME LEVEL OF EFFICIENCY.
WHAT ARE SOME EXAMPLES OF HARDWARE?
MONITOR, MOUSE, KEYBOARD & PRINTER
“CPU” IS AN ABBREVIATION FOR
CENTRAL PROCESSION UNIT
WHAT IS THE FIRST THING THE MEDICAL ASSISTANT SHOULD DO WHEN ANSWERING A TELEPHONE CALL?
IDENTIFY THE PRACTICE & HIM/HER SELF
WHEN ANSWERING THE TELEPHONE, WHAT IS THE BEST QUESTION FOR THE MEDICAL ASSISTANT TO ASK TO FIND OUT A CALLER’S NAME?
“MAY I ASK WHO IS CALLING, PLEASE”
HOW OFTEN SHOULD THE MEDICAL ASSISTANT CHECK BACK WITH A CALLER WHO IS ON HOLD?
AT LEAST EVERY 30 SECONDS
WHAT IS THE NAME OF THE TELEPHONE FEATURE THAT ALLOWS A MEDICAL ASSISTANT TO SEND CALLS FROM ONE TELEPHONE NUMBER OR EXTENSION TO ANOTHER?
CALL FORWARDING
WHEN IS CALL FORWARDING USED?
WHEN ALL CALLS ARE REROUTED TO ANOTHER TELEPHONE NUMBER
WHAT IS IT CALLED WHEN THE MEDICAL ASSISTANT DETERMINES WHICH TELEPHONE CALLS WILL GO TO THE PHYSICIAN?
SCREENING
WHEN ARE APPOINTMENT REMINDERS CALLS USUALLY PLACED TO PATIENTS
24-48 HOURS BEFORE THE APPOINTMENTS
WHAT IS THE NAME OF THE SCHEDULE PATIENTS WITH SIMILAR PROBLEMS OR CONDITION ON CERTAIN DAYS?
CLUSTERING SCHEDULE
WHAT SYSTEM SCHEDULE THREE OR FOUR PATIENTS EVERY HALF HOUR, WHO ARE SEEN IN THE ORDER WHERE THEY ARE ARRIVE
WAVE SCHEDULING
WHAT IS THE GOAL OF STREAM SCHEDULING?
TO SCHEDULE PATIENTS SO THAY THERE IS A STEADY FLOW OF PATIENTS MOVING THROUGH THE OFFICE
WHAT IS THE ADVANTAGE OF THE OPEN OFFICE HOURS?
THEY GIVE MORE PATIENTS FLEXIBILITY
WHAT IS THE ADVANTAGE OF AN ELECTRONIC MEDICAL RECORD SYSTEM?
LESS SPACE IS REQUIRED FOR RECORD STORAGE
WHAT IS AN OUTGUIDE?
A STIFF PIECE OF PAPER OR PLASTIC THAT IS PLACED IN A FILE WHEN A MEDICAL RECORD IS REMOVED
WHAT IS A PATIENT SURNAME?
LAST NAME
WHAT IS THE SECOND INDEXING UNIT IN ALPHABETIC FILING?
FIRST NAME
HOW DO YOU STORE PATIENTS FILES INFORMATION BY
SURNAME (LAST NAME) FIRST THEN, FIRST INDEXING UNIT (FIRST NAME)
WHAT IS THE FIRST FILING UNIT FOR THE NUMBER
01-68-72-59
59
WHAT ARE SOME EXAMPLES OF WHEN MEDICAL ASSISTANT OPENS THE MEDICAL OFFICE?
TURNS OFF ALARM
UNLOADS AUTOCLAVE
TURNS ON RADIO, TELEVISION, AND/OR DVD PLAYER IN THE WAITING ROOM
FILLS PAPER TRAYS OF COPIER AND PRINTER
WHAT ARE SOME EXAMPLES OF WHEN A MEDICAL ASSISTANT IS CLOSING THE MEDICAL OFFICE?
SETS THE ALARM
LOADS AUTOCLAVE
TURNS OFF RADIO, TELEVISION, AND/OR DVD PLAYER IN THE WAITING ROOM
MAKES BACKUP COMPUTER COPIES
