BUSINESS WRITING FINAL Flashcards
what are the four components of POMR document?
database, problem list, treatment plan, progress notes
what is considered demographic data in a patients medical record?
address, phone number, social security #
what is the purpose of a thorough and accurate medical record?
document patients evaluation and change in the patients condition, provide communication with physician and staff
what does “www.” mean?
world wide web
what title of HIPAA covers access, portability and renewal of health insurance?
title 1
when a patient is deceased, this would be considered what type of file?
closed
if a patient has not been in your office for 2-3 years, their medical record would be with what type of file?
inactive
what are some reasons for keeping medical records?
used to continue care, evaluated quality of treatment received, also for malpractice, suits brought upon against a doctor
what can you do to notify a recipient that an email is important?
flag it
how often should you change passwords and long-in codes?
every 30 days
what is an advance directive?
instructions from the patient regarding of their end of life decisions
how long should yo keep a child’s medical record?
3 years from their 18 birthday
what is a HIPAA officer?
someone that oversees and coordinates various aspects of compliance
what is a covered entity?
those who must adhere to regulations under HIPAA guidelines
in what section of the medical record would you find the chief complaint?
clinical
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?
document the note with today’s date, put chart in late entry, for the date and time of the phone call
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?
document in the subjective component
how many components are there in a business letter?
11
what is a physical exam report?
report of the physicians objective findings
what is a component that can be observed by the examiner?
objective symtom
what is a prognosis?
probable outcome of a patients condition
how is the word California typed or written on the recipient’s address on an envelope?
CA
what is a problem-orientated medical record?
list each problem of the patient at the beginning at the chart, assigns each problem a #
what is a diagnosis?
disease or condition that a patient has
what is a clearinghouse?
an entity that receives reviews sends and manages insurance claims for a physican
what is a flow sheet?
graphic or table form
what is the standard margin in a business letter?
1 inches
how can you protect your computer from viruses and protect your medical records?
do not open email from someone you do not know, make a backup of all files, and start backup files off the premises
only standard abbreviations should be used in business letters?
true
what is a progress notes?
documentation of patients encounter in the office including any phone calls and prescriptions refills
abbreviation in medical records should be accepted for use in the office before you can begin using them?
true
are the margins the same or different on page two or a letter?
same
what is a referral?
the transfer of patients care to a specialist
what is the chief complaint?
reason for the visit to the doctors office
what is considered chronological order?
in order of time
can confidentiality be guaranteed in an email?
no
what is a narrative note?
a paragraph indicating contact of the patient including what was done, and the outcome of any suggestions of an treatment
what is an subjective symptom?
a statement by the patient of what they are feeling
what is a health history report?
collection of subjective and objective data
how do you type a salutation to a physician?
Dear Doctor____:
what is a medical impression?
conclusion drawn by the physician after gathering data and interpreting it
what is the purpose of an agenda?
briefly outlines the topic of the meeting
explain the difference between a Full block and a Semiblock letter:
full block, everything is justified left; semi block has indented paragraphs, date and closing
what is the golden rule regarding documentation?
if it’s not documented, it is considered not done
correction fluid can be used on patient charts in the office?
false
can you copy all information that you download from the internet?
no
would you list patients illness on a patient registration form?
no
you can give information about a patient to anyone that that calls and states they are authorized to get that information from you?
no
can you release an original copy of the patients chart if it is subpoenaed by the court?
yes
you can not use abbreviations on medical records?
false
does a progress note contain updated information about the patient?
yes
the health history provides what data to assist the physician in arriving at a diagnosis?
subjective and objective data
can a medical record serve as a legal document?
yes
does the physician legally own the original coy of the patient chart?
yes
would you send patient information over the internet to a site that does not have a SSL?
no
