Chapter 11

Question 1

-Medical records should include the following general information about the patient

Answer 1

• Address and phone number
• Occupation
• Medical history
• Current complain or condition
• Healthcare needs
• Treatment plan or services
  -Radiology and lab reports
• Response care

Question 2

If information is not documented______

Answer 2

no one can prove that an event or a procedure took place.

Question 3

What is documentation?

Answer 3

Is the process of recording information in the medical

Question 4

What is the term noncompliant?

Answer 4

Is the medical term used to describe when the patient is not following the medical advice

Question 5

What happen when there is inappropriate or inaccurately in a patient’s medical record in a court of law?

Answer 5

The practitioner also will be held responsible for that action

Question 6

Patient medical records are frequently used to evaluate the quality of care and treatment a facility or specific physician provides.

Answer 6

Quality of Care

Question 7

Team may be testing a new antihypertensive drug with volunteers who fit a certain medical category perhaps males between the ages of 45 and 54

Answer 7

Medical Research

Question 8

What is the second part of the registration process?

Answer 8

The patient past medical history
- Illness, Surgeries, known allergies, and current medication, family history, social history and occupational.

Question 9

Patient medical history is also know

Answer 9

As the history of present illness or HPI.

Question 10

What is the review of system ?

Answer 10

Is an inventory of the body obtained by the healthcare provider through a series of questions.

Question 11

What the purpose of review of systems?

Answer 11

To identify any signs or symptoms the patient is experiencing that reveal information about an illness or condition.

Question 12

What is the hospital discharge summary?

Answer 12

The reason the patient entered the hospital

Question 13

What include in the hospital discharge:

Answer 13

• Date of admission
• History of present illness
• Date of discharge
• Admitting diagnosis
• Surgeries or procedures
• Complications
• Patient instructions for follow up
• Discharging physician’s signature

Question 14

What is a consent form?

Answer 14

Is a signed informed consents must be obtained when any procedure is being performed on a patient.

Question 15

Dating and Initialing you should

Answer 15

must be careful not only to date everything you put into the patient chart but also to initial each entry.

Question 16

Patient information is arranged within the medical record according to the provider type supplying the data.

Answer 16

Source-oriented medical record (SOMR)

Question 17

What includes SOMR?

Answer 17

Includes areas for data from the patient treating provider, specialist, labs, hospitals or other locations to document in the record

Question 18

One way to overcome the disadvantages of the source-oriented approach is to use the

Answer 18

problem-oriented medical record (POMR)

Question 19

Includes a record of the patients past medical history; information gained in the initial interview with the patient.

Answer 19

Database

Question 20

Each condition or diagnosis a patient has is listed seperately and given its own number, including the date onset.

Answer 20

Problem List

Question 21

Signs are

Answer 21

objective or external

Question 22

Symptoms are

Answer 22

subjective or internal

Question 23

Each problem should have a

Answer 23

detailed educational, diagnostic, and treatment summary in the record

Question 24

Are entered for each problem listed in the initial record.

Answer 24

Progress note

Question 25

What stand each letter in SOAP?

Answer 25

S - Subjective data from the patient
O - Objective data come from the practitioner, examination
A - Assessment is the diagnosis or impressions
P - Plan of action treatment options

Question 26

Cheddar stand for:

Answer 26

-C: Chief complaint
-H: History past medical history
-E: Examination
-D: Details of problem and complaints
-D: Drug and dosage
-A: Assessment of diagnostic process
-R: Return of visit

Question 27

Every time a patient has has an X-ray or lab test or a letter arrives from a specialist order should be

Answer 27

inserted into the medical record and always in reverse chronological order which means the most current result will always be on the top

Question 28

1- Client’s word

Answer 28

Be careful to record the patient exact words rather than your interpretation of them

Question 29

2- Clarity

Answer 29

Use precise description and accepted medical terminology when describing a patients condition

Question 30

3- Completeness

Answer 30

Fill out completely all the forms used in the patient record

Question 31

4- Concisness

Answer 31

While striving for clarity also be concise or brief and to the point

Question 32

5- Chronological order

Answer 32

All entries must be dated to show the order in which they are made

Question 33

6- Confidentiality

Answer 33

Always remember that the information from the patient should be confidential

Question 34

Means transforming spoken notes into accurate written form

Answer 34

Transcription

Question 35

The healthcare provider must be able to trust the _______ of the information in the medical records.

Answer 35

Accuracy

Question 36

What is the proper way to correct a mistake in a medical record?

Answer 36

Draw a single line through the error, making sure that the original entry is still legible.

Question 37

If there is not enough room near the error to make full correction make

Answer 37

make a notation near the error as to where in the chart the correction may be found. and note the date and reason for the correction and initial the completed correction

Question 38

Steps for realizing medical information

Answer 38

1- Obtain a signed and newly dated release from the patient
2- Make photocopies of the material
3- Call the recipient to confirm that all materials were received.

Question 39

The a audit a record means

Answer 39

a records means to examine and a review a group of patient records for completeness and accuracy

Question 40

What is internal audits?

Answer 40

The medical staff can perform internal audits.

Question 41

What is external audits?

Answer 41

Government entities managed care organizations and private insurance carriers perform external audits.