past medical history (PMI)
patient's history of medical problems, including chronic conditions, surgeries, and hospitalizations
note documenting the care delivered to a patient, and the medical facts and clinical thinking relevant to diagnosis and treatment
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)
Patient allergies are recorded and stored in the Rx/Medications folder of the patient chart. (T/F)
A typical patient flow consists of check-in, patient intake, examination, and checkout. (T/F)
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)
Medications that have been added, discontinued, or changed are noted in the patient chart. (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.
The ________ documents the care delivered to a patient, and the medical facts and clinical thinking relevant to diagnosis and treatment.
________ are sent to patients, other providers, employers, insurance companies, and others.
In most practices, the ________ is entered as the title of the progress note for the patient's visit.
A(n) ________ is a mild reaction to a medication and does not involve an immune system response.
Abnormally high blood pressure readings are highlighted in ________ in the Vital Signs dialog box.
To open a patient chart, click Open Chart on the File menu or click the ________ toolbar button.
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.
The information about a patient's past medical history is located in the Past Medical History ________ in the patient's chart.
A blue ________ in the upper-right corner of a folder in a patient's chart indicates that the folder contains information.
The Social History folder is located between the Past Medical History and the Family History folder in a patient's chart.
A patient's social history contains information about personal habits such as smoking and drinking. (T/F)
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 ________.
A blue rectangle in the corner of the Family History folder indicates that information has been entered in the folder. (T/F)
The Allergy dialog box contains a field to record the date and time the allergy was identified. (T/F)
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.
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.
Medications that a patient is taking are listed in the ________ tab of the Rx/ Medications dialog box.
A shared note ________ is used when information in a progress note is entered by more than one person.
To open a shared note, click the ________ button in response to the question about whether you want to edit an existing shared note.
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.
The ________ button on the toolbar is used to log out of Medisoft Clinical Patient Records, without closing down the program.
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.
When a user has a new message waiting in the inbox, the Msg button on the toolbar is ________.
When the ________ button in the Messages dialog box is clicked, the relevant section of a patient's chart opens.
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.
When a template is used to create a letter, the program automatically enters some of the information. (T/F)