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Today's Medical Assistant > Ch # 38: The Medical Record > Flashcards

Ch # 38: The Medical Record Flashcards

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USMLE® Step 1 flashcards
1
Q

The name 4 a physician who is responsible 4 the care of a hospitalized patient

A

Attending Physician

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2
Q

The statement of the most important symptom(s) 4 which a patient is seeking care

A

Chief complaint

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3
Q

A clinical section of the medical record

It’s a narrative report of an opinion about a patient’s condition from a practitioner other than the attending physician

Requirements 4 this report include:
- documentation that the physician reviewed the patient's health     
   history and examined the patient
- physician's impressions
- any care or treatment provided
- any recommendations
A

Consultation report

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4
Q

The scientific method of determining and identifying a patient’s condition

A

Diagnosis

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5
Q

A procedure performed 2 assist in the diagnosis, management or treatment of a patient’s condition

This type of procedure can include a variety of reports:

  • EKG
  • holter monitor
  • spirometry
  • radiology
  • diagnostic imaging
A

Diagnostic procedure

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6
Q

A picture that is stored electronically 2 allow viewing on a computer

A

Digital image

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7
Q

A brief summary of the significant events of a patient’s hospitalization

A

Discharge summary report

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8
Q

The process of making written or electronic entries about a patient in the medical record

A

Documenting

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9
Q

2 names 4 a patient health record that is stored on a computer

Contains important health info on the patient including the care received and the progress of the patient’s condition

It incorporates software 4 scheduling, billing and filing insurance claims

A

Electronic medical record
(EMR)

Electronic health record
(EHR)

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10
Q

Occurring in or affecting members of a family more frequently than would be expected by chance

A

Familial

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11
Q

A paper document or electronic screen that allows similar data 2 b recorded and viewed chronologically

A

Flow sheet

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12
Q

A collection of subjective data about a patient

A

Health history

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13
Q

A type of continuity of care report

The provision of medical and nonmedical care in a patient’s home or place of residence because familiar surroundings contribute positively to a patient’s emotional and physical well-being (and is a lot cheaper than inpatient care).

This must be ordered by a patient’s physician 4 the purpose of minimizing the effect of disease or disability by promoting, maintaining and restoring the patient’s health.

The skilled professional that provides the care must periodically provide a summary report 2 the patient’s physician and includes the following information:

  • observations and evaluations
  • type of care or service provided
  • instructions given 2 the patient about medications
  • safety measures recommended 4 the home
  • diet
  • activities permitted
A

Home health care

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14
Q

A patient who has been admitted 2 a hospital 4 atleast 1 overnight stay

A

Inpatient

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15
Q

A written record of important information regarding a patient, including the care of that individual and progress of the patient’s condition

Serves as a legal document

A

Medical record

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16
Q

The way that a medical record is organized

2 types: source-oriented record
problem-oriented record

A

Medical record format

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17
Q

A symptom that can b observed by an examiner

A

Objective symptom

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18
Q

2 names 4 a medical record in paper form

It’s more time consuming and takes up a lot of storage space compared 2 digital records

A

Paper-based patient record

Problem-oriented medical record

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19
Q

An assessment of each part of the patient’s body 2 obtain objective data about the patient that assists the physician in determining the patient’s state of health

A

Physical examination

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20
Q

Any condition that requires further observation, diagnosis, management or patient education

A

Problem

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21
Q

Arranging documents w/the most recent document on top or in front, which means the oldest document is on the bottom or at the back of a section or file

A

Reverse chronological order

22
Q

A method of organization 4 recording progress notes

Contains 4 categories: Subjective data
Objective data
Assessment
Plan

A

SOAP

23
Q

A symptom that is felt by the patient but is not observable by an examiner

A

Subjective symptom

24
Q

Any change in the body or it’s functioning that indicates the presence of disease

A

Symptom

25
Q

Was part of the 2009 stimulus package that has accelerated the adoption of EMR’s because of financial incentive payments 4 medical offices that made the conversion

A

Health Information Technology 4 Economic and Clinical Health Act

(HITECH)

26
Q

A type of record format that is used for organizing a paper-based patient records

They r organized in2 sections based on the department, facility or other source that generated the info. Within each section the documents r arranged by date

Because documents from each source r filed 2gether, it is easier 2 compare info from lab or diagnostic test results, assessments and treatments

A

Source-oriented record

27
Q

A type of medical record format that is organized according
2 the patient’s health problems

Developed in 4 stages:

1) establishing a database
2) compiling a problem list
3) devising a plan of action 4 each problem
4) following each problem w/progress notes

Allows 4 each of the patient’s problems 2 b defined and followed individually

A

Problem-oriented record

POR or POMR

28
Q

1st step in developing a POR

Consists of a collection of objective and subjective data:

  • health history report
  • physical examination report
  • results of lab or diagnostic tests

This information is used to identify and compile a problem list

A

Database

29
Q

2nd step in developing a POR

This is a list of all the patient’s conditions and they require observation, diagnosis, management or patient education

This list is made up of physiological, psychological and social problems.

A

Problem list

30
Q

3rd step in developing a POR

This involves devising a course to take for further evaluation and treatment 4 each problem

A

Plan

31
Q

4th and final step in developing a POR and a clinical section of the medical record

This section is up dated every time the patient visits or calls the medical office and is documented and signed by the MA (this includes credentials, date and time)

This is the follow-up stage 4 each problem the patient has and is organized in2 4 categories:

1) Subjective data
2) Objective data
3) Assessment
4) Plan

A

Progress notes

32
Q

A type of medical record format that combines elements from the POR and the source-oriented formats.

This record is divided in2 3 categories:

1) clinical
2) scheduling
3) billing

A

EMR format

33
Q

A type of administrative form

It consists of demographic and billing information

This information is used 4:

  • scheduling appointments
  • posting patient transactions
  • processing patient statements and insurance claims
A

Patient registration records

34
Q

A type of administrative form

A written document that explains 2 patients how their protected health information (PHI) will be used and protected by the medical office.

A

Notice of Privacy Practices

NPP

35
Q

A type of administrative form

This form names an individual 2 make medical decisions 4 the patient should the patient become incapacitated and/or state the patient’s wishes if they become unable 2 direct care

A

Advanced directives

36
Q

A type of administrative form

This form is a legal document that is required in order 2 perform certain procedures or 2 release information contained in the patient’s medical record

This signed form is required 2 perform all surgeries and nonroutine therapeutic and diagnostic procedures

A

Consent form

37
Q

A type of administrative form

Anything other than medical treatment, payment or health care operations require this detailed form be filled out and signed by the patient or legal guardian

Data requirements 4 this form include:

  • patient’s full name and address
  • name of the medical practice releasing the PHI
  • name of individual or faculty receiving the PHI
  • specified information 2 b released
  • purpose or need 4 the information
  • method of release of the PHI
  • signature of the patient or legal guardian
  • date signed
  • expiration date
A

Medical records release form

38
Q

A type of administrative form

This form is filled out anytime anyone or any facility contacts the medical office regarding the patient (including the patient)

A

Correspondence and messages

39
Q

A type of administrative form

This form contains information on future appointments and payment information

A

Schedule and billing information

40
Q

A section of the medical record that includes a variety of records and reports that assist the physician in the care and treatment of the patient

These sections include the patient’s:

  • database
  • problem list
  • progress notes
  • laboratory data
  • diagnostic procedures
  • continuity of care
A

Clinical section

41
Q

A clinical section of the medical record

The information of the patient it includes are:

  • health history
  • physical examination
  • allergies
  • medication record
A

Database

42
Q

A clinical section of the medical record

This section is up dated at every time the patient has an appointment so that active problems can b identified.

It helps the provider organize and plan appropriate care 4 the patient

A

Problem list

43
Q

A clinical section of the medical record

These reports are usually filled 2gether in a paper-based medical record and can b accessed from 1 tab in an EMR

A

Laboratory data

44
Q

A type of diagnostic procedural report

This is a narrative report of a cardiologist’s interpretation of an EKG test and it includes the implications 4 the patient

A

EKG report

45
Q

A type of diagnostic procedural report

This is a narrative description of the interpretation of a 24 - 48 hour EKG and includes the evaluator’s impressions

A

Holder monitor report

46
Q

A type of diagnostic procedural report

This is a narrative and graphic description of the interpretation of a patient’s breathing capacity as measured w/a spirometer

A

Spirometry report

47
Q

A type of diagnostic procedural report

A narrative description of a diagnostic or therapeutic radiologic procedure and includes a detailed interpretation of the radiograph and their impressions

A

Radiology report

48
Q

A type of diagnostic procedural report

This is a narrative description of a diagnostic imaging procedure and includes a detailed interpretation of the diagnostic image and the practitioner’s impressions

A

Diagnostic imaging report

49
Q

A clinical section of the medical record

This section is 4 summary care reports which are generated anytime a patient is referred 2 another setting of care or provider of care.

This section includes a variety of reports:

  • consultation
  • home health care
  • therapeutic service documents
  • hospital documents
A

Continuity of care

50
Q

A type of continuity of care report

This type of report documents the assessments and treatments designed to restore a patient’s ability 2 function.

Some examples include:

  • physical therapy
  • occupational therapy
  • speech therapy
A

Therapeutic services documents

51
Q

A type of continuity of care report

These documents are prepared by the attending physician anytime a patient stay’s in the hospital or visits the ER. A copy is sent to the patient’s primary care physician and this aide’s the primary in reviewing the hospital visit and providing follow-up care.

A

Hospital documents

Today's Medical Assistant (46 decks)

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