HIM 110 - Chapter 6 Homework

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past medical history (PMI)

patient's history of medical problems, including chronic conditions, surgeries, and hospitalizations

progress note

note documenting the care delivered to a patient, and the medical facts and clinical thinking relevant to diagnosis and treatment

patient flow

progression of patients from the time they enter the officer for a visit until they exit the system by leaving the office after a visit

family history (FH)

detailed record of medical events among the patient's relatives, including the ages, living status, and diseases of siblings, children, parents, and grandparents

social history (SH)

information about the patient's tobacco use, alcohol and drug use, sexual history, relationship status, and other significant social facts that may contribute to the care of the patient

history of present illness (HPI)

a description of the course of the present illness, including how and when the problem began, up to the present time

review of systems (ROS)

an inventory of body systems in which the patient reports signs or symptoms he or she is currently having or has had in the past

PFSH (past, family, and social history)

a commonly used abbreviation for past medical, family, and social history

false (Vital Signs folder)

Patients' vital sign measurements are entered in the Progress Notes folder in the patient chart. (T/F)

false (a single note)

Each history section of a patient's chart consists of multiple notes. (T/F)

true

Patient allergies are recorded and stored in the Rx/Medications folder of the patient chart. (T/F)

true

A typical patient flow consists of check-in, patient intake, examination, and checkout. (T/F)

true

The first step in opening a patient chart is to select Open Chart on the File menu or to click the Chart button on the toolbar. (T/F)

false (Patient Lookup dialog box)

The History dialog boxes are used to select a patient. (T/F)

true

Using Medisoft Clinical Patient Records, staff members can send intra-office messages. (T/F)

true

Medications that have been added, discontinued, or changed are noted in the patient chart. (T/F)

true

The history of present illness (HPI) includes previous treatment and diagnostic tests. (T/F)

false (title of progress note)

A patient's chief complaint is recorded in the Medical History folder of the patient chart. (T/F)

past medical history (PMH)

The________ is the patient's history of medical problems, including chronic conditions, surgeries, and hospitalizations.

social history (SH)

The________ is information about the patient's tobacco use, alcohol and drug use, sexual history, relationship status, and other significant social facts that may contribute to the care of the patient.

family history (FH)

The________ details medical events among members of the patient's family, including the ages, living status, and diseases of siblings, children, parents, and grandparents.

progress note

The ________ documents the care delivered to a patient, and the medical facts and clinical thinking relevant to diagnosis and treatment.

Letters

________ are sent to patients, other providers, employers, insurance companies, and others.

Current, Ineffective, and Historical

The ________ tabs are in the Rx/Medications dialog box.

chief complaint

In most practices, the ________ is entered as the title of the progress note for the patient's visit.

intolerance

A(n) ________ is a mild reaction to a medication and does not involve an immune system response.

red

Abnormally high blood pressure readings are highlighted in ________ in the Vital Signs dialog box.

Msg

To open a new message in the inbox, select the ________ button on the toolbar.

Chart

To open a patient chart, click Open Chart on the File menu or click the ________ toolbar button.

OK

Once the patient's name is selected, clicking the ________ button open the patient's chart.

Lookup

After entering letters from the patient's last name in the Last Name field of the Patient Lookup dialog box, click the ________ button to search for the patient.

folder

The information about a patient's past medical history is located in the Past Medical History ________ in the patient's chart.

rectangle

A blue ________ in the upper-right corner of a folder in a patient's chart indicates that the folder contains information.

date and time

The first line of a past medical history note lists the ________.

OK

To save information entered in a social history note, click the ________ button.

Family History

The Social History folder is located between the Past Medical History and the Family History folder in a patient's chart.

true

A patient's social history contains information about personal habits such as smoking and drinking. (T/F)

three

How many history folders are in a patient chart in Medisoft Clinical Patient Records?

age

The information in the top of the Fmaily History note dialog box that cannot be changed in the note include the patient's ID, date of birth, and ________.

true

A blue rectangle in the corner of the Family History folder indicates that information has been entered in the folder. (T/F)

Rx/Medications

To enter an allergy in a patient chart, click the Rx/Medications folder.

true

The Allergy dialog box contains a field to record the date and time the allergy was identified. (T/F)

Miscellaneous

The options in the Allergy Type drop-down list in the Allergy dialog box are Drug Allergy, Drug Intolerance, Food Allergy, and ________.

Rx Template Code

To lookup a template for a medication, an entry is made in the ________ field of the Prescription dialog box.

Outside

To indicate that a medication has been prescribed by a physician who is not in the practice, click the ________ box in the Prescription dialog box.

Current

Medications that a patient is taking are listed in the ________ tab of the Rx/ Medications dialog box.

signature

A shared note ________ is used when information in a progress note is entered by more than one person.

Signature

The Enter Signature dialog box contains two fields: Operator ID and ________.

Yes

To open a shared note, click the ________ button in response to the question about whether you want to edit an existing shared note.

true

The Vital Signs dialog box records the date and time that vital signs are recorded, as well as the operator entering the information. (T/F)

in red type

Vital sign readings that are above the normal range are displayed ________ in the Vital Signs dialog box.

Click the Vital Signs folder, Click the New button, Complete the entries in the Vital Signs (new) dialog box, Click the OK button, Click the Close button

Arrange the steps into the correct order for entering and saving a patient's vital signs.

Park

The ________ button on the toolbar is used to log out of Medisoft Clinical Patient Records, without closing down the program.

Select Destination

The recipient of a message is selected in the ________ dialog box.

Click the Msg button on the toolbar, Click the New button, Click the To... button, Click the entry for the desired recipient and then click the To->> button on the right side of the dialog box, Complete the Type, Priority, and Date to activate fields, Enter the chart number and name of the patient, Enter the message in the body of the note, Click the Send button

Arrange the steps into the correct order for creating and sending a new message.

blue

When a user has a new message waiting in the inbox, the Msg button on the toolbar is ________.

Link

When the ________ button in the Messages dialog box is clicked, the relevant section of a patient's chart opens.

deleted from

When the Record button in the View Message dialog box is clicked, the message is recorded in the patient's chart and ________ the recipient's inbox.

Insert Template

Letter templates are listed in the ________ dialog box.

true

When a template is used to create a letter, the program automatically enters some of the information. (T/F)

blue

Labels in the letters templates are underlined and displayed in ________.

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