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SEQUENCE 2 FINAL > BUSINESS WRITING FINAL > Flashcards

BUSINESS WRITING FINAL Flashcards

1
Q

what are the four components of POMR document?

A

database, problem list, treatment plan, progress notes

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2
Q

what is considered demographic data in a patients medical record?

A

address, phone number, social security #

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3
Q

what is the purpose of a thorough and accurate medical record?

A

document patients evaluation and change in the patients condition, provide communication with physician and staff

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4
Q

what does “www.” mean?

A

world wide web

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5
Q

what title of HIPAA covers access, portability and renewal of health insurance?

A

title 1

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6
Q

when a patient is deceased, this would be considered what type of file?

A

closed

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7
Q

if a patient has not been in your office for 2-3 years, their medical record would be with what type of file?

A

inactive

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8
Q

what are some reasons for keeping medical records?

A

used to continue care, evaluated quality of treatment received, also for malpractice, suits brought upon against a doctor

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9
Q

what can you do to notify a recipient that an email is important?

A

flag it

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10
Q

how often should you change passwords and long-in codes?

A

every 30 days

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11
Q

what is an advance directive?

A

instructions from the patient regarding of their end of life decisions

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12
Q

how long should yo keep a child’s medical record?

A

3 years from their 18 birthday

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13
Q

what is a HIPAA officer?

A

someone that oversees and coordinates various aspects of compliance

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14
Q

what is a covered entity?

A

those who must adhere to regulations under HIPAA guidelines

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15
Q

in what section of the medical record would you find the chief complaint?

A

clinical

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16
Q

how would you document a telephone conversation you had several days ago with a patient and forgot to make a note in the patients chart?

A

document the note with today’s date, put chart in late entry, for the date and time of the phone call

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17
Q

when using the SOAP format in charting, where would you find the information if a patient states that they have been having stomach pain for 12 hours?

A

document in the subjective component

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18
Q

how many components are there in a business letter?

A

11

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19
Q

what is a physical exam report?

A

report of the physicians objective findings

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20
Q

what is a component that can be observed by the examiner?

A

objective symtom

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21
Q

what is a prognosis?

A

probable outcome of a patients condition

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22
Q

how is the word California typed or written on the recipient’s address on an envelope?

A

CA

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23
Q

what is a problem-orientated medical record?

A

list each problem of the patient at the beginning at the chart, assigns each problem a #

24
Q

what is a diagnosis?

A

disease or condition that a patient has

25
Q

what is a clearinghouse?

A

an entity that receives reviews sends and manages insurance claims for a physican

26
Q

what is a flow sheet?

A

graphic or table form

27
Q

what is the standard margin in a business letter?

A

1 inches

28
Q

how can you protect your computer from viruses and protect your medical records?

A

do not open email from someone you do not know, make a backup of all files, and start backup files off the premises

29
Q

only standard abbreviations should be used in business letters?

A

true

30
Q

what is a progress notes?

A

documentation of patients encounter in the office including any phone calls and prescriptions refills

31
Q

abbreviation in medical records should be accepted for use in the office before you can begin using them?

A

true

32
Q

are the margins the same or different on page two or a letter?

A

same

33
Q

what is a referral?

A

the transfer of patients care to a specialist

34
Q

what is the chief complaint?

A

reason for the visit to the doctors office

35
Q

what is considered chronological order?

A

in order of time

36
Q

can confidentiality be guaranteed in an email?

A

no

37
Q

what is a narrative note?

A

a paragraph indicating contact of the patient including what was done, and the outcome of any suggestions of an treatment

38
Q

what is an subjective symptom?

A

a statement by the patient of what they are feeling

39
Q

what is a health history report?

A

collection of subjective and objective data

40
Q

how do you type a salutation to a physician?

A

Dear Doctor____:

41
Q

what is a medical impression?

A

conclusion drawn by the physician after gathering data and interpreting it

42
Q

what is the purpose of an agenda?

A

briefly outlines the topic of the meeting

43
Q

explain the difference between a Full block and a Semiblock letter:

A

full block, everything is justified left; semi block has indented paragraphs, date and closing

44
Q

what is the golden rule regarding documentation?

A

if it’s not documented, it is considered not done

45
Q

correction fluid can be used on patient charts in the office?

A

false

46
Q

can you copy all information that you download from the internet?

A

no

47
Q

would you list patients illness on a patient registration form?

A

no

48
Q

you can give information about a patient to anyone that that calls and states they are authorized to get that information from you?

A

no

49
Q

can you release an original copy of the patients chart if it is subpoenaed by the court?

A

yes

50
Q

you can not use abbreviations on medical records?

A

false

51
Q

does a progress note contain updated information about the patient?

A

yes

52
Q

the health history provides what data to assist the physician in arriving at a diagnosis?

A

subjective and objective data

53
Q

can a medical record serve as a legal document?

A

yes

54
Q

does the physician legally own the original coy of the patient chart?

A

yes

55
Q

would you send patient information over the internet to a site that does not have a SSL?

A

no

SEQUENCE 2 FINAL (3 decks)

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