Ch 1 - Medical Records and History

Question 1

what does HIPAA stand for?

Answer 1

health insurance portability and accountability act

Question 2

provider’s impression

Answer 2

diagnosis

Question 3

medical record

Answer 3

a written record of the important information regarding a PT, including the care of that individual and the progress of his or her condition

also serves as a legal document

Question 4

Consequence of incomplete medical records?

Answer 4

used as evidence in court to show that a PT did not receive the quality of care that meets generally accepted standards

Question 5

examples of office administrative documents

Answer 5

patient registration record
notice of privacy practices acknowledgement form
correspondence

Question 6

examples of medical office clinical documents

Answer 6

health history report
physical examination report
progress notes
medication record
consultation report
home health care report

Question 7

examples of laboratory reports

Answer 7

hematology
clinical chemistry
immunology
urinalysis
microbiology
parasitology
cytology
histology

Question 8

examples of diagnostic procedure reports

Answer 8

electrocardiogram
holter monitor
colonoscopy
spirometry
radiology
diagnostic imaging

Question 9

examples of therapeutic reports

Answer 9

physical therapy report
occupational therapy report
speech therapy report

Question 10

definition of medical administrative documents

Answer 10

administrative documents contain information necessary for efficient management of the medical office

Question 11

definition of medical office clinical documents

Answer 11

medical office clinical documents include a variety of records and reports that assist the provider in the care and treatment of the PT

Question 12

examples of hospital documents

Answer 12

history and physical
operative
discharge summary
pathology
emergency department

Question 13

examples of consent documents

Answer 13

consent to treatment

release of medical information

Question 14

what is the HIPAA privacy rule?

Answer 14

provide PT with better control over the use and disclosure of their health information

all health care providers, health plans, and health care clearinghouses that use, store, or transmit health information must comply with this rule

Question 15

What is Notice of Privacy Practices

Answer 15

NPP must explain to PT how their PHI will be used and protected by the medical office

medical office must make reasonable effort to provide a NPP to each PT and obtain a signed acknowledgement from the PT to prove they have received a NPP

Question 16

what is considered PHI?

Answer 16

health information that contains patient identifiable information

eg. name, SSN, telephone

Question 17

examples of when a PT’s written consent is not required for the use or disclosure of PHI

Answer 17

medical treatments: PT referral to a specialist, emergency care at hospital, tests on pt performed by the laboratory

payment: determination of eligibility for insurance benefits, review of services provided for medical necessity, utilization review activities

health care operations: quality assessment activities, contacting PT with information about care or tx, employee review activities, training of health care students

Question 18

examples of business associates whom the medical office may disclose PHI with respects to HIPAA Privacy Rule

Answer 18

medical laboratories
transcription services
law firms
accounting firms
software and hardware consultants
billing services

Question 19

what is a health history report?

Answer 19

a collection of subjective data about the PT

Question 20

diagnosis

Answer 20

scientific method of determining and identifying a PT’s condition

Question 21

list the seven parts of the health history

Answer 21

identification data
chief complaint
present illness
past history
family history
social history
review of systems

Question 22

what is a chief complaint?

Answer 22

identifies the PT’s reason for seeking care

the symptom that is causing the PT the most trouble

Question 23

how to document the Chief Complaint?

Answer 23

open ended question
limit to one or two symptoms
concise and brief
onset/duration of the symptom
never use diagnostic terms

specific location of area, intensity, precipitating factors

Question 24

what is a present illness?

Answer 24

an expansion of the chief complaint and includes a full description of he PT’s current illness from the time of its onset

the MA completes this section by asking questions to elicit detailed information

Question 25

examples of past history?

Answer 25

major illnesses
childhood diseases
unusual infections
accidents and injuries
hospitalizations and operations
previous medical tests
immunizations
allergies
current medications

Question 26

examples of familial diseases

Answer 26

diabetes mellitus
hypertension
heart disease
allergies

Question 27

examples of social history

Answer 27

education
occupation
living environment
diet
personal history
exercise

Question 28

how to correct a mistake in documentation in PPR?

Answer 28

draw a single line through incorrect information
write the word ‘error’ above incorrect data
including date MA’s first initial and last name, and credentials

Question 29

what are progress notes?

Answer 29

document the PT’s health status and the care and treatment being received by the PT in chronological order

Question 30

how to document a procedure?

Answer 30

date and time
type of procedure
outcome
patient reaction

Question 31

how to document administration of medication?

Answer 31

date and time
name of medication
lot number
dosage
route of administration
injection site used
significant observations 
PT reactions

Question 32

how to document a specimen collection?

Answer 32

date/time
type of specimen
area of body specimen was obtained
note if sent to outside laboratory
date sent
where it was sent

Question 33

how to document in house laboratory tests?

Answer 33

date/time
name of test
test results

Question 34

other examples that require documentation from the MA?

Answer 34

missed or canceled appointments
telephone calls from PT
medication refills
changes in medication or dosage by provider

Question 35

definition of a symptom

Answer 35

any change in the body or its functioning that indicates the presence of disease