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MEDICAL RECORDS REVIEW PURPLE MOD FORTIS INSTITUTE TOWSON (MEDIX) MR Y

WHEN THE NAMES OF TWO OR MORE INDIVIDUALS ARE EXACTLY THE SAME, THE FIRST CONSIDERATION AFTER THE NAME FOR INDEXING IS

STATE

INDICATE THE THIRD INDEXING UNIT FOR THE NAME "MR. JOHNSON MARC BERMAN, JR."

MARC

WHAT IS CONSIDERED TO BE SUBJECTIVE

ANYTHING THE PATIENT TELLS YOU

"SOAP" STANDS FOR

SUBJECTIVE, OBJECTIVE, ASSESSMENT, PLAN

TO INDICATE A FOLER HAS BEEN REMOVED FROM THE FILING CABINET AND IS IN SOMEONE'S POSSESSION, YOU WOULD USE A(N)

OUTGUIDE

INDEXING IS A STEP IN FILING WHICH

FILING IS BASED ON INDEXING UNITS

WHAT IS OBJECTIVE INFORMATION

DATA FROM THE MA, MD, TESTS, OR MEASUREMENT RESULTS

THE ORDER IN WHICH PROGRESS NOTES, LABORATORY RESULTS, X-RAY REPORTS, ETC., ARE ADDED TO THE PATIENT'S MEDICAL RECORD IS

CHRONOLOGICAL ORDER WITH THE MOST RECENT ON TOP

ALL MEDICAL RECORDS ARE CONSIDERED TO BE THE PROPERTY OF THE PHYSICIAN, BUT NO ONE CAN SEE A PATIENT'S MEDICAL RECORD WITHOUT

WRITTEN CONSENT, COURT SUBPOENAED, OR CONTAGIOUS DISEASES

A DIAGNOSIS BASED SOLELY ON THE EVALUATION OF THE HEALTH HISTORY OF THE PATIENT AND THE PHYSICAL EXAMINATION FINDINGS IS CALLED A(N)

CLINICAL DIAGNOSIS

THE PROCEDURE FOR FILING REPORTS AND LETTERS REQUIRE SEVERAL STEPS. WHAT IS THE LAST (FINAL) STEP IN THE FILING PROCESS

FILING AND SORTING

WHEN LEGAL ACTION IS TAKEN AGAINST A PHYSICIAN, MEDICAL RECORDS CAN

PROVIDE LEGAL DEFENSE OR PROTECTION

A NOTATION IN A FILE THAT INDICATES A CERTAIN PAPER IS IS FILLED ELSEWHERE IS REFERRED TO AS A(N)

CROSS REFERENCE

PHOTOCOPIES OF PATIENT INFORMATION RECEIVED BY FAX TRANSMISSION ON THERMAL PAPER SHOULD ALWAYS BE PHOTOCOPIED BEFORE PLACING IN THE PATIENT'S CHART BECAUSE

THERMAL PAPER FADES OVER TIME

WHEN ERRORS REGARDING INFORMATION ARE NOTED IN THE PATIENT'S CHART, THEY MUST BE CORRECTED USING LEGALLY ACCEPTABLE TECHNIQUES. WHAT IS THE PROPER PROCEDURE FOR CORRECTING AN ERROR IN A MEDICAL RECORD

1. DRAW A SINGLE LINE THROUGH THE ERROR
2. INSERT THE CORRECTION ABOVE OR IN THE MARGION OF THE ERROR
3. WRITE ERROR NEXT TO THE ERROR AND SIGN AND DATE THE MISTAKE

A TYPE OF FILE THAT IS SET UP TO REMIND PATIENTS TO COME FOR THEIR REGULAR CHECKUPS IS COMMONLY REFERRED TO AS A

TICKLER FILE

THE PROCESS OF REMOVING ALL PINS AND PAPER CLIPS FROM THE PAPERS PRIOR TO FILING IS REFERRED TO AS

CONDITIONING

THE "PROBLEM-ORIENTED' MEDICAL RECORD IS

DIVIDED INTO FOUR DIVISIONS USING THE "SOAP" APPROACH

WHICH PORTION OF THE MEDICAL HISTORY IS SUPPLIED BY THE PATIENT

SUBJECTIVE INFORMATION

WHAT IS THE ONE THING THAT YOU SHOULD NEVER DO WHEN CORRECTING A MEDICAL RECORD

ERASE OR OBLITERATE AN ERROR

WHERE WOULD THE MOST LOGICAL PLACE BE TO FILE AN ARTICLE ABOUT HIV INFECTION

UNDER "H" IN THE LIBRARY OR SUBJECT FILING

ANY INDICATION OF DISEASE OR ILLNESS PERCEIVED BY THE PATIENT IS REFERRED TO AS A(N)

SYMPTOM

WHERE WOULD YOU FIND A FILE FOR "THE HENRY WILSON MEDICAL INSTRUMENTS COORPORATION

UNDER "W" FOR WILSON

THE ART OF DISTINGUISHING BETWEEN TWO SIMILAR DISEASES BY CONTRASTING THEIR SYMPTOMS IS CALLED

DIFFERENTIAL DIAGNOSIS

WHAT IS THE FOURTH INDEXING UNIT FOR THIS NAME: "THE MARTIN COLE MEDICAL INSTRUMENTS COMPANY"

INSTRUMENTS

ONE OF THE MOST IMPORTANT DUTIES OF A MEDICAL ASSISTANT IS TO

FILL OUT AND MAINTAIN ACCURATE AND THOROUGH PATIENT RECORDS

THE ROLE THE MEDICAL ASSISTANT PLAYS IN PATIENT EDUCATION IS TO EXPLAIN

THE MANAGEMENT OF THEIR CONDITION AS DESCRIBED BY THE DOCTOR

HOW ARE PATIENT RECORDS USED IN MEDICAL RESEARCH

STATISTIC REASONS, PATIENT RESPONSES, BEHAVIOR OF MEDICATIONS, SIDE EFFECTS OF MEDICATIONS, AND OUTCOME OF MEDICATIONS

WHAT OF THE FOLLOWING INFORMATION IS FOUND ON THE PATIENT REGISTRATION FORM

PERSONAL DATA: NAME, DATE OF BIRTH, ADDRESS, PHONE NUMBER, NEXT OF KIN, INSURANCE, ETC.

A SUMMARY OF THE REASON THE PATIENT ENTERED THE HOSPITAL, THE CARE THE PATIENT RECEIVED IN THE HOSPITAL, AND THE OUTCOME IS FOUND IN THE

DISCHARGE SUMMARY FORM

THE BEST WAY TO MAKE SURE THE PHYSICIAN SEES A PATIENT'S X-RAY REPORT BEFORE FILING IS TO

HAVE THEM INITIAL THE FILE

A PHYSICIAN TRIES UNSUCCESSFULLY TO CALL A PATIENT. THE MEDICAL ASSISTANT SHOULD

DOCUMENT IT IN THE CHART

THE "O" SECTION OF "SOAP" DOCUMENTATION IS

OBJECTIVE CLINICAL EVIDENCE

THE "A" SECTION OF "SOAP" DOCUMENTATION IS

ASSESSMENT FOR DIAGNOSIS

THE "P" SECTION OF "SOAP" DOCUMENTATION IS

PLANS FOR FUTURE STUDIES, TREATMENT, OR MANAGEMENT

WHEN MAY A PHYSICIAN RELEASE A PATIENT'S MEDICAL RECORD

WRITTEN CONSENT, COURT SUBPOENAED, OR CONTAGIOUS DISEASES

WHEN IS IT APPROPRIATE TO SEND THE ORIGINAL DOCUMENT

NEVER

THE REASON A PATIENT'S RECORD WOULD NOT BE SENT BY FAX MACHINE IS BECAUSE

YOU DO NOT KNOW WHO COULD GET IT

WHEN DO MOST STATES CONSIDER CHILDREN TO BE ADULTS WITH THE RIGHT TO PRIVACY

18

THE FIRST STEP TO UPDATING A PATIENT'S MEDICAL RECORD IS TO

VERIFY THAT YOU HAVE THE RIGHT RECORD FOR THE RIGHT PATIENT

A MEDICAL RECORD FROM ANOTHER PHYSICIAN SHOULD BE

FILED IN THE CURRENT RECORD IN CHRONOLOGICAL ORDER

WHICH OF THE FOLLOWING IS A GUIDELINE FOR ARRANGING FILES IN ALPHABETICAL ORDER

1. LAST NAME, FIRST NAME, MIDDLE NAME
2. INITIALS BEFORE NAME WITH SAME LETTER
3. HYPHENATED NAMES DELETE THE HYPHEN
4. DELETE APOSTROPHES
5. FOREIGN NAMES ASSUME IN NORMAL ORDER
6. PREFIXES FOLLOW ALPHABET
7. SPELL OUT ABBREVIATION
8. MARRIED WOMEN MAY USE SEVERAL DIFFERENT VERSIONS OF HER NAME, BUT WILL NEVER USE HER HUSBANDS FULL NAME
9. DISREGARD ALL TITLES EXCEPT ROYALTY AND CLERGY
10. DISREGARD ARTICLES
11. DISREGARD TERMS OF SENIORITY
12. COMPANY NAMES BEARING A PERSONS NAME FOLLOW THE SAME RULES AS NAME FILING
13. COMPANY NAMES BEARING A LIST OF PERSONS NAMES ARE FILED AS THEY APPEAR
14. OTHER COMPANY NAMES USE WORDS IN ORDER OF APPEARANCE
15. NOTHING BEFORE SOMETHING

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