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Medical Admin
Question | Answer |
---|---|
What is the common method of filing? | Alphabetic |
What best describes the proper way to index personal names? | (Last name) (First name) (MI) |
Hyphenated names are considered what? | one unit |
Put in order: 1)Sr. 2)lll 3)4th 4)11 5)Jr. 6)5th | 1)4th 2)5th 3)ll 4)l 5)Jr. 6)Sr. |
What is the importance of medical records accuracy? | Critical for smooth functioning and for legal issues. |
What office tool helps to ensure charts may be tracked down when borrowed? | An Outguide- paper or file that lets someone know where a patients file is and when it will be returned. |
Rule 3 of filing? | Nothing before something |
What is indexing? | Placing items in filing order. |
What is the name of a mark placed on a document after it is determined that no further follow up is needed? Who makes that mark? | Release Mark; Physician or Provider |
S in SOAP meaning | Subjective- what patients c/c is and symptoms |
O in SOAP meaning | Objective-signs, what you can see |
A in SOAP meaning | Assessment- diagnosis |
P in SOAP meaning | What the physician's plan is to make patient better. |
Describe in the proper way to correct an error in a chart | Put a single line going thru the word with initial over it. |
What is the term used for the main reason for a patients visit? | Chief Complaint. c/c |
Subjective findings are also known as | Symptoms |
Objective findings are also known as | Signs |
What is the information an out guide should contain besides the date a chart was removed? | Why is it being removed, Who has removed it, where did it go to, when will it return. |
Heredity tendencies | Family History (FH) |
Tends to detect conditions other than those covered in present | Review of Systems |
Hobbies, interests, methods of exercise | Social History |
Covers dates and quests regarding previous complaints | Past History |
Eating, drinking, smoking and sleeping habbits | Social History |
Typically reason for visit | Chief Complaint |
Conclusion physician reaches after evaluating all findings | Diagnosis |
X-rays, Blood work, UA | Laboratory Reports |
PMHx reports, Physical Exams, Follow-up notes | Clinical notes |
Outside letters from other physicians, clinical offices | Correspondeneces |
Insurance related papers, requests for transfer or medical records, anything not related to direct treatment of the patient. | Miscellaneous |
Release Mark | Used to let staff know an item was signed off and may be filed in the chart. |
Purging | The method of removing files from the office that are no longer in use. |
Out guide | A tool used to insure that records are tracked when borrowed. |
POMR | Method by which problems are identified by the number that corresponds to the problem. |
ROS | Guide to general health that tends to detect condition other than those covered by present illness |
Symptom | Perceptible only to patient |
Cardinal Symptom | Symptom of the greatest significance to the overall condition. |
SOMR | Groups information in the chart according to category. |
Signs | Perceptible to another person. |
Cross Referencing | Card or sheet that may be used when name is indexed in more than one way |
Hyphenated names are separated into 2 units for filing | False |
North West is the same as Northwest in filing | False |
Symbols in company names are spelled out. | True |
Punctuation is ignored in filing, | True |
Records are retained for 7 years and certain files put on microfilm before destroying | True |
MA's do a review of systems before the physician sees the patient | False |
The last name ST. Mark would be spelled out and indexed as Saint Mark | False |
CC | Chief Complaint |
DX | Diagnosis |
FMHX or FH | Family History |
PMH | Past medical History |
CPE or PE | Complete physician exam |
H&P | History and physical |
MFH | Maternity family history |
PFH | Paternal family history |