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42 terms

MEDICAL RECORDS REVIEW

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