amnio (sac surrounding embryo)
urinary bladder, cyst
larynx (voice box)
spinal cord, bone marrow
resembling, derived from
falling, drooping, prolapse
surgical puncture to remove fluid
berry shaped bacterium
correct spelling for study of the eye?
the correct spelling of record of the spinal cord?
correct spelling for enlargement of the liver?
record of blood vessels?
correct spelling for inflammation of the tonsils?
pain of a muscle?
resembling the chest?
correct spelling for surgical puncture to remove fluid from the abdomen?
study of the urinary bladder?
correct spelling for new opening of the trachea?
clusters of new openings?
correct spelling for pertaining to surrounding the heart?
surgical removal of the voice box?
correct spelling for hardening of the arteries?
blood condition of holding back blood (from cells or part)?
correct spelling for pleural pain?
fear of heights (extremities)?
correct spelling for clusters of berry-shaped bacterium?
fleshy tumor of muscle?
study of shape (of cells)?
drooping of eyelid?
softening of cartilage?
tumor of bone marrow?
disease of heart muscle?
findings during the examination or interview with the patient?
this file section contains prescription copies or documentation?
outguide or folder
this is used to temporarily replace a file that has been removed?
dates of injuries, treatment, notes regarding patient's condition
what are the 3 things that are included in a patient history file?
draw a single line, write correction above, initial, date, include why correction was made
what is the proper procedure for correcting a handwritten entry on a progress note?
complaints, signs, and symptoms as described by the patient?
this section of file holds x-rays and non-lab reports and testing information?
some office attach lab reports to a file in this fashion?
complete medical history
this serves as a basis for planing patient care?
abnormal lab results, rx refills, patient concerns
3 types of call backs that should never be left for the next day?
treatments, medications, surgery or other recommended action?
a chronological record of each visit, prescription refill, calls and other encounters should be filed under?
this reminds an individual of a task that needs to be completed?
Information supplied by the patient?
spell name correct, keep organized/neat, proper filing, update timely/appropriately, write legibly in black ink
5 steps toward proper records management?
the diagnosis or evaluation of the patient?
follow-up letters from other professionals and insurance companies should be filed under?
the process of cleaning out and removing files when cabinets become full and have no room for other charts?
when a shorter surname is identical with the first part of a longer surname, which is listed first?
inspect, index, coding, sort, storing
5 steps to remember when filing?
where does it go
highlight pt name
arrainging, put in order
designed to establish a relationship between the patient profile, complaints, reivew of systems, physical examination, laboratory findings and other relevent information?
results of blood testing should be filed under?
information supplied by the physician?
Most offices use the same number of these for each patient when using numerical filing?
date, time am/pm, who you spoke to, discussion, patient questions, unable to reach, document pt chart
describe the important points of documenting follow up calls when calling a patient regarding 'normal' test results?
date & name of physician
If dictating and transcribing are used to chart patients visits, this must be included on the dictation notes?
computer, word processing
primary peice of equipment use to transcribe
these pose many safety hazards (hint: peice of furniture)?
track files, decreases search time, reduce lost files, eliminates outguides
3 Pros for using Bar Codes on files?
These type of records usually begin with the patient's general information for billing and scheduling?
eraser and correction fluid
When making corrections, you never use these (2 items)?
When filing, you should fill this drawer first to prevent injury?
track referrals, f/u's and re-check appts
The main purpose of a tickler file?
make sure each piece is released for filing
First step when filing reports and letters?
CMS (centers for medicare and medicaid service) cannot review this item when auditing files?
requires you to decide the name, subject or other caption under which you will file the material?
progress notes are arranged in this order with the most recent date on top?
index the materials
Second step in filing reports and letters?
regulates electronic information and ways to protect it from invasion, accidental disclosure, or loss of the records?
save time, quality pt care
explain why accurate filing should be done daily?
the material is arranged in numerical order in the main file, and the main file is supplemented by an alphabetically arranged index card?
locate the file drawer with the appropriate caption
Final step when filing reports and letters?
must be assigned to track who has access to PHI within a medical office?
DVDs, CD-ROMs, memory sticks
In a paperless office today, electronic information can be stored using these modes?
Most filing system are ______ based?
liability, patient care
reasons why it is important to include the date and time on all progress notes?