Study Guide Ch 11,16,37,45 Fill out and maintain accurate and thorough patient records is the most ____for a Medical Assistant important duty Pt medical history and present condition is found where? Medical record also known as charts Patient care management, patient records are used for ? Continuity/Quality of care, communication tool, research, and legal documentation The medical assistant may help _________ about his condition or its management, as requested by ___________. Educate the patient, the physician Pt illness and reason for visit is found in the ___________. History of Present Illness (HPI) Hospital Discharge Summary generally includes? Admission/Discharge dates, HPI, diagnosis, treatment, follow-up care instructions, physician’s signature, complications (if any) The first document found in a pt’s financial record is? Patient Registration Form Initialing imaging reports helps ? To show who is responsible for the entry also to see if practitioner has reviewed them Where should you interview a patient? Private area to have confidentiality You need to distinguish between signs and symptoms. An example of a sign is ________ A fever, rash, or swelling (what other people can tell) You need to distinguish between signs and symptoms. An example of a symptoms is ________ Headache or Nausea (how you feel inside) Signs are External factors that are seen or measured by others Symptoms are Internal factors that are stated by the patient What does each letter of SOAP stands for Subjective, Objective, Assessment, Plan Blue ink is recommended to ensure what? Originality, readability, and fraud prevention Test results should be record ____________ Immediately and accurately Typical time for an CPE is? 30-60 minutes Typical time for f/u appt is? 5-15 minutes The disadvantage of an open-hours scheduling system is? Uneven patient flow (inefficient downtime for office staff) & long wait times What is time-specified scheduling? Where patients arrive at regular, specified intervals, ensuring the practice of a steady stream of patients Wave scheduling is? Several patients seen in the same hour, seen in order they arrived; determined by dividing the hour by the length of the average visit and then giving that number of patients appointments with the doctor at the beginning of each hour Double-booking? 2 or more patients are scheduled at same time slot, assuming both will be seen within the period Advance scheduling is useful in __________ or __________in which a pts are generally booked wks or months in advance. Annual checkups or consultations Advantages of computerized scheduling? Blocks time for emergency or last-minute visits. Lets staff see the schedule from anywhere in the office. Shows which patients cancel or don’t show up often. Helps find and schedule follow-up appointments easily. Makes reports to track how scheduling is going. Uses colors to organize different types of appointments. Lets you search for open days or times quickly
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