medical records

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42 terms · P103 theory

When the names of two or more individuals are exactly the same, the first consideration after the name for indexing is.

State, city, street name, street number, date of birth

Indicate the third indexing unit for the name Mr. Johnson marc Herman, Jr

Marc

What is considered to be subjective

Information provided by the patient/system

SOAP stands for

Subjective, objective, assessment, plan

To indicate a folder had been removed from the filing cabinet and is in someone's possession, you would use an

Outguide

Indexing is a step in filing which

Decides where to file the letter/ paper

What is objective information

Information provided by the physician, ma, or what you see

The order in which progress notes, laboratory reports. x-ray reports, etc., are added to the patients medical record is

Chronologically

All medical records are considered to be the property of the physician, but no one can see a patients medical record without

Patient consent or authorization

A diagnosis based sorely on the evaluation of the health history of the patient and physical examination findings is called an

Clinical diagnosis

The procedure for filing reports and letters requires several steps. What is the last (final) step in the filing process

Locate draw itself, place papers with heading to left and most current on top

When legal action is taken against a physician, medical records can

Support physician in defense against a claim (subpoena)

A notation in a file that indicates a certain paper is filed elsewhere is referred to as an

Cross-reference

Photocopies of patients information received by fax transmission on thermal paper should always be photocopied before placing in the patients chart because

Thermal paper fade and can become unreadable

When errors regarding information are noted in the patients chart, they must be corrected using legally acceptable technique. What is the proper procedure for correcting an error in a medical record

Draw a single line through info, note recorded in area, initial and date

A type of file that is set up to remind patients to come in 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 feferred to as

Conditioning

The problem-oriented medical record is

Plan for patient care using SOAP

Which portion of the medical history is supplied by the patient

Subjective

What is the one thing that you should never do when correcting a medical record

Do not erase

Where would the most logical place be file an article about HIV infection

By subject in physcian filing

Any indication of disease or illness perceived by the patient is referred to as an

Symptom

Where would you find a file for henry wilson medical instruments corporation

The letter H

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 accuracte and thorough information

The role the medical assistant plays in patient education is to explain

the management of the patients condition as outlined by the physcian

How are patient records are used in medical research

Patient responeses, behavior, side effects, and outcome

What of the following information is found on the patien regristration form

Address

a summary ocf the reason the patient enetered 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 physcian sees a patients X-ray report before filing it is to

Have the physcian initial reports

A physcian tries unsuccessfully to call a patient. The medical assistant should

Record date of call in patients records

The O section of soap documentation is

Data that comes from a physcian

The A section of soap documentation is

Diagnosis

The P section of soap documentation is

Plan of action include treatment injucation follow up

when may a physcian release a patients record

In case of contajous disease or when subpoena by court

When is it appropriate to send the original document

Never

The reason a patients record would no be sent by fax machine is because

No way to see who will see the document

When do most states consider children to be adults with the right to privacy

18

The first step to updating a patients medical record is to

Verify you have the right record for the right patient

A medical record from another physcian should be

Entered into the patients charts

Which of the following is a guideline for arranginging files in alphabetical order

Hypenated names is considered a single unit

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