Chapter 11: Med Test Flashcards
The assessment portion of the medical records helps to document the evaluation of the patient
to form a diagnosis or plan of treatment
The primary purpose of medical documentation is to help health professionals
communicate with one another
Physician’s _____________ consist of directives for tests, treatments, medications, and follow-up care.
orders
T/F: A patient’s medical record is considered a legal record of their medical history and health care.
True
A flow sheet contains a graphic record of a patient’s __________________.
vital signs
Progress notes that record information in a paragraph style use a ________________ format.
narrative
An ____________ sheet includes demographic data and insurance information provided by the patient prior to receiving care.
admission
Military time is based on a _____ hour cycle.
24-hour
Most health care facilities have converted from paper records to which format?
Electronic medical records
What are the benefits of using electronic physician’s orders?
fewer errors due to lost paperwork or misread orders
What is the purpose of progress notes?
To record every contact a provider has with a patient
Why is a family history included in the patient’s history?
Certain disorders and diseases are inherited
T/F: Health care facility quality assurance efforts include the review of patient medical records.
True
What is a problem-oriented medical record?
Medical record that organizes information according to the patient’s symptoms or complaints
What is objective data in a medical record as opposed to subjective data?
Objective Data: Data in the medical record that document observations of the patient made by the health provider
Subjective Data: Statements made by the patient about his or her complaint or condition
What is a source-oriented medical record?
Medical record that organizes information according to its type or where its originated
What are the advantages of computerized medical records?
They include the ability to accessed by multiple users via portable electronic files
What is a key benefit of electronic charting?
Entries can be made faster and are easier to read than on paper
What does SOAP stand for in SOAP Notes?
Subjective Data, Objective Data, Assessment, Plan
Medical records include codes that document diagnoses and ____________________.
health care services provided
A ___________ history is a record of a patient’s lifestyle, including occupation, education, marital status, diet, and alcohol and tobacco use.
social
Why is military time used in health care?
It prevents the confusion between (AM) morning and (PM) night
What is “Charting by exception”?
Is a form of progress notes that records information in an abbreviated format
