Medical Office II Week 1

Created by mrc13b2006 

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119 terms · Medical Office II Week 1

amni/o

amnio (sac surrounding embryo)

angi/o

vessel (blood)

cyst/o

urinary bladder, cyst

isch/o

hold back

laryng/o

larynx (voice box)

my/o

muscle

myel/o

spinal cord, bone marrow

staphyl/o

clusters, uvula

thorac/o

chest

acr/o

extremities, top

blephar/o

eyelid

cardi/o

heart

chondr/o

cartilage

morph/o

shape, form

sarc/o

flesh

lapar/o

abdominal wall

mamm/o

breast

adip/o

fat

hepat/o

liver

pulmon/o

lung

arteri/o

artery

trache/o

trachea (windpipe)

tonsil/o

tonsil

abdomin/o

abdomen

pleur/o

pleura

ophthalm/o

eye

-oid

resembling, derived from

-ole

little, small

-dynia, -algia

pain

-gram

record

-stomy

new opening

-ectomy

removal, excision

-emia

blood condition

-logy

study of

-malacia

softening

-oma

tumor, mass

-phobia

fear

-plasia

development, formation

-ptosis

falling, drooping, prolapse

-pathy

disease

-penia

deficiency

-trophy

nourishment, development

-itis

inflammation

-centesis

surgical puncture to remove fluid

-cocci, -coccus

berry shaped bacterium

-sclerosis

hardening

-therapy

treatment

peri-

surrounding

ophthalmology

correct spelling for study of the eye?

myelogram

the correct spelling of record of the spinal cord?

hepatomegaly

correct spelling for enlargement of the liver?

angiogram

record of blood vessels?

tonsilitis

correct spelling for inflammation of the tonsils?

myalgia

pain of a muscle?

thoracoid

resembling the chest?

abdominocentesis

correct spelling for surgical puncture to remove fluid from the abdomen?

cystology

study of the urinary bladder?

-plasty

surgical repair?

tracheostomy

correct spelling for new opening of the trachea?

staphylostomy

clusters of new openings?

pericardium

correct spelling for pertaining to surrounding the heart?

laryngectomy

surgical removal of the voice box?

arteriosclerosis

correct spelling for hardening of the arteries?

ischemia

blood condition of holding back blood (from cells or part)?

pleurodynia

correct spelling for pleural pain?

acrophobia

fear of heights (extremities)?

staphylococci

correct spelling for clusters of berry-shaped bacterium?

myosarcoma

fleshy tumor of muscle?

morphology

study of shape (of cells)?

blepharoptosis

drooping of eyelid?

chondromalacia

softening of cartilage?

myeloma

tumor of bone marrow?

cardiomyopathy

disease of heart muscle?

objective

findings during the examination or interview with the patient?

medication

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?

subjective

complaints, signs, and symptoms as described by the patient?

diagnostic information

this section of file holds x-rays and non-lab reports and testing information?

shingle

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?

plan

treatments, medications, surgery or other recommended action?

progress notes

a chronological record of each visit, prescription refill, calls and other encounters should be filed under?

tickler file

this reminds an individual of a task that needs to be completed?

subjective?

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?

assesment

the diagnosis or evaluation of the patient?

correspondence

follow-up letters from other professionals and insurance companies should be filed under?

purging

the process of cleaning out and removing files when cabinets become full and have no room for other charts?

shorter

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?
devide
where does it go
highlight pt name
arrainging, put in order
file shelf

POMR

designed to establish a relationship between the patient profile, complaints, reivew of systems, physical examination, laboratory findings and other relevent information?

lab reports

results of blood testing should be filed under?

objective

information supplied by the physician?

digits (numbers)

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

file cabinet

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?

computer-generated

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)?

bottom

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?

financial reports

CMS (centers for medicare and medicaid service) cannot review this item when auditing files?

indexing

requires you to decide the name, subject or other caption under which you will file the material?

chronological

progress notes are arranged in this order with the most recent date on top?

index the materials

Second step in filing reports and letters?

security rule

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?

numerical filing

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?

privacy officer

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?

alphabetically

Most filing system are ______ based?

liability, patient care

reasons why it is important to include the date and time on all progress notes?

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