abbrevs and questions
Quiz yourself by thinking what should be in
each of the black spaces below before clicking
on it to display the answer.
Help!
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| adl | show 🗑
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| bp | show 🗑
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| CC | show 🗑
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| show | Central Nervous System
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| CPE/PE | show 🗑
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| show | Date Of Birth
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| show | Diagnosis
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| F.Hx | show 🗑
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| show | No Appreciable Disease
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| NYD | show 🗑
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| show | Electronic Medical Records
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| CPP | show 🗑
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| show | Signs & Symptoms
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| show | Patient Oriented Medical Records
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| SOAP | show 🗑
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| wt. | show 🗑
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| show | Treatment
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| TPR | show 🗑
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| SHx | show 🗑
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| Rx | show 🗑
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| show | Rule Out
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| show | Patient
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| Prog. | show 🗑
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| PI | show 🗑
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| What is meant by the term "Health Record"? | show 🗑
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| List 5 uses of a health record | show 🗑
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| show | It is a folder containing all the records relating to a clients care with a facility. Papre or Computerized.
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| show | Clients name, address, birth date & health card number. Must be kept neat, accurate & complete. Each encounter & service entered. Stored safely & properly. Kept confidential, relevent history obtained, results, advice given.
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| show | History, CPP, list of allergies, physical assessment, lab sheets or reports, consultation reports/letters, growth chart.
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| show | Removing a file from active status & storing it in a secondary location. When a patient leaves for any reason or dies. Must be maintained for 10yrs after the date of last contact.
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| Explain the process of "purging" a chart. | show 🗑
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| show | Alphabetic:last name first, followed by first name. *Oldest and the easiest. Numeric: Sequential order or terminal digit. Colour coding: Each letter or number may have a specific colour.
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| show | Centralized is designated to one Centralized location, which houses all records ex. Hospital Health Information Services. Decentralized is allowing parts of the patient record to reside in other areas, ex. in a hospital.
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| What is an auxiliary files? When would you use this? | show 🗑
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| show | System must provide a means of access to the record of each client, by name & possibly health card number. Must be able to print recorded information promptly. Must include security password. System must automatically back up files & allow for recovery.
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| If records are computerized what criteria must be met according to the OMA? continued.. | show 🗑
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| Outline the life cycle of a record, describe first 2 stages. | show 🗑
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| show | Provision: Policies will dictate who may have access to patient record, for what purposes & for how long. Disposition: Is considered active if the client is active & may seek treatment.Chart cannot be destroyed for 10yrs but may be purged.
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To hide a column, click on the column name.
To hide the entire table, click on the "Hide All" button.
You may also shuffle the rows of the table by clicking on the "Shuffle" button.
Or sort by any of the columns using the down arrow next to any column heading.
If you know all the data on any row, you can temporarily remove it by tapping the trash can to the right of the row.
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Created by:
Brittanyyy
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