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119 terms

Medical Office II Week 1

Medical Office II Week 1
STUDY
PLAY
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?