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42 terms

medical records

P103 theory
STUDY
PLAY
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