Chapter 11 test

Question 1

what are the general information the medical records should include?

Answer 1

address, phone number, occupation, medical history, current complaint, healthcare needs, medical treatment plan, lab work, response to care.

Question 2

as a general rule if it isn’t documented it…

Answer 2

didn’t happen

Question 3

how long should a medical record be kept until it can be destroyed?

Answer 3

7 years

Question 4

the process of recording information in the medical record.

Answer 4

documentation.

Question 5

what color should you write in?

Answer 5

blue ink

Question 6

the medical term used to describe a patient who does not follow the medical advice he or she receives.

Answer 6

noncompliant.

Question 7

patient health records can be used to ____ patients about their own conditions and treatment plans.

Answer 7

educate.

Question 8

the TJC ( The Joint Commission ) may review medical records to monitor whether the care provided and the fees charged meet accepted standards.

Answer 8

quality of care.

Question 9

a medical record also pays an important role in…

Answer 9

research.

Question 10

people who volunteer to get tested on and get paid while doing it is usually done for…

Answer 10

research

Question 11

specific information required about the population.

Answer 11

demographics,

Question 12

the second part of the registration process, contains the patients past…

Answer 12

medical history.

Question 13

when should you update a medical form?

Answer 13

address changes, marital status, etc.

Question 14

what do you do when you make a change on the medical form?

Answer 14

one line, and initial.

Question 15

the 6 C’s

Answer 15

Client’s words, Clarity, Completeness, Conciseness, Chronological order, Confidentiality.

Question 16

internal audits

Answer 16

done by the people in the office

Question 17

external audits

Answer 17

done by the state, government,

Question 18

the information requested in the registration form itself is fairly uniform and generally includes

Answer 18

date of current(first) visit, patients legal name and physical address, phone numbers including area code, patients DOB, sex, marital status, and SS#, medical insurance information, employer name/address, and occupation, emergency contact name, relationship, and phone number, primary care physician.

Question 19

the second part of the patient registration, also known as the history of present illness, or HPI.

Answer 19

Patient Medical History

Question 20

What does HPI stand for?

Answer 20

history of present illness.

Question 21

the review of systems is an “inventory” of the body obtained by the healthcare provider through a series of questions, also called…

Answer 21

Physical Examination Form

Question 22

Hospital Discharge Summaries include

Answer 22

date of admission, history of present illness(HPI), date of discharge, admitting diagnosis, surgeries procedures, or hospital course, complications(if any)discharging physicians signature.

Question 23

date of admission, history of present illness(HPI), date of discharge, admitting diagnosis, surgeries procedures, or hospital course, complications(if any)discharging physicians signature.

Answer 23

Hospital Discharge Summaries

Question 24

Physical Examination Form

Answer 24

the review of systems is an “inventory” of the body obtained by the healthcare provider through a series of questions

Question 25

Patient Medical History

Answer 25

the second part of the patient registration, also known as the history of present illness, or HPI.

Question 26

demographics

Answer 26

specific information required about the population.

Question 27

consent forms

Answer 27

the patient also should be informed of the possible outcome if the patient receives no treatment, as well as be informed of any alternative treatments and possible risks.

Question 28

dating and initialing

Answer 28

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

Question 29

makes it easy to identify who in the practice is responsible for each entry.

Answer 29

initialing

Question 30

SOMR

Answer 30

Source Oriented Medical Record

Question 31

what does SOMR mean?

Answer 31

patient information is arranged within the chart or medical record according to who supplied the data–the patient, treating physician, specialist, or hospital. these records describe all problems and treatments on the same form in simple chronological order.

Question 32

what Is SOMR sometimes called?

Answer 32

conventional method

Question 33

POMR

Answer 33

Problem Oriented Medical Records

Question 34

what does POMR mean?

Answer 34

makes it easier for the physician to keep track of a patients progress. includes the following items, database; problem list; educational; diagnostic, and treatment plan, and progress notes.

Question 35

Signs

Answer 35

something that can be seen; are objective, or external factors— like blood pressure, rashes, or swelling

Question 36

something that can be seen; are objective, or external factors— like blood pressure, rashes, or swelling

Answer 36

Signs

Question 37

Symptoms

Answer 37

something that cant be seen; subjective or internal, conditions felt by the patient– like nausea, headache, or pain

Question 38

something that cant be seen; subjective or internal, conditions felt by the patient– like nausea, headache, or pain

Answer 38

Symptoms

Question 39

SOAP

Answer 39

Subjective, Objective, Assessment, Plan

Question 40

what does SOAP mean?

Answer 40

Subjective-data comes from the patient, the patient describes his or her signs and symptoms; Objective- data comes from the physician, examinations, and test results; Assessment-the diagnosis of the problem; Plan of action-includes treatment options, chosen treatment, tests, and follow ups.

Question 41

CHEDDAR

Answer 41

Chief Complaint, History, Examination, Details, Drugs and Dosage, Assessment, Return

Question 42

Whats does CHEDDAR mean?

Answer 42

Chief Complaint-presenting problems, subjective statements; History-past medical, family, and social histories; Examination-extent of body systems examined; Details-of problems or complaints; Drugs and Dosage- a list of current medications including dosage and frequency; Assessment-the diagnosis process and the impression made by the physician; Return-follow up, visit, if applicable

Question 43

Updating Medical Forms

Answer 43

if address changes, name changes, phone number changes, etc. add the date and your initials.

Question 44

follow up

Answer 44

RECORD EVERYTHING! notes the doctor dictates about the patients progress, post laboratory results, record telephone calls; must be dated and the conversation must be documented, must initial the entry, record any medical instructions(discharge), counsel or educate the patient regarding treatment, or home care procedures.

Question 45

transforming spoken words into accurate written form

Answer 45

Transcription

Question 46

handwritten notes, you should…

Answer 46

use a good quality pen that will not smudge or smear, HIPPA requires all original documents be maintained in the patients records, in blue ink! use highlighting pens to call attention, make sure all handwriting is legible, make any corrections to the chart

Question 47

timeliness includes…

Answer 47

record all exam and test results, if you forget, enter the date of receipt and the date the report was entered into the record, to document telephone calls, record the date and time of the call, who initialed it, the info discussed, any conclusions or results, establish a procedure for retrieving a file quickly in case of emergency

Question 48

Accuracy includes

Answer 48

never guess at or assume knowledge of names, procedures, medications, etc, ALWAYS ASK! double check the accuracy of findings and instructions recorded on the chart, make sure the latest info has been entered into the chart.

Question 49

Using care with corrections you should…

Answer 49

draw a single line through a mistake, making sure the original entry is still legible. write or type the corrected info above or below the original entry. note the date and the reason for the correction.

Question 50

procedures of releasing records…

Answer 50

obtain a signed and newly dated release from the patient authorizing the transfer of specific information, make photocopies, call the recipient to confirm that all materials were received.

Question 51

confidentiality

Answer 51

when children reach age 18 most states consider them as an adult, therefore they DONOT have to let their parents know or see their medical records.

Question 52

internal audits

Answer 52

done by the people their self, in their office.

Question 53

external audits

Answer 53

done by people outside the office, ( Medicare and Medicaid)

Question 54

done by people outside the office, ( Medicare and Medicaid)

Answer 54

external audits

Question 55

done by the people their self, in their office.

Answer 55

internal audits

Question 56

obtain a signed and newly dated release from the patient authorizing the transfer of specific information, make photocopies, call the recipient to confirm that all materials were received… is procedures to….

Answer 56

releasing records…

Question 57

draw a single line through a mistake, making sure the original entry is still legible. write or type the corrected info above or below the original entry. note the date and the reason for the correction is….

Answer 57

Using care with corrections

Question 58

never guess at or assume knowledge of names, procedures, medications, etc, ALWAYS ASK! double check the accuracy of findings and instructions recorded on the chart, make sure the latest info has been entered into the chart is including….

Answer 58

Accuracy

Question 59

record all exam and test results, if you forget, enter the date of receipt and the date the report was entered into the record, to document telephone calls, record the date and time of the call, who initialed it, the info discussed, any conclusions or results, establish a procedure for retrieving a file quickly in case of emergency which is…

Answer 59

timeliness

Question 60

what should you use a good quality pen that will not smudge or smear, HIPPA requires all original documents be maintained in the patients records, in blue ink! use highlighting pens to call attention, make sure all handwriting is legible, make any corrections to the chart

Answer 60

handwritten notes

Question 61

RECORD EVERYTHING! notes the doctor dictates about the patients progress, post laboratory results, record telephone calls; must be dated and the conversation must be documented, must initial the entry, record any medical instructions(discharge), counsel or educate the patient regarding treatment, or home care procedures. for a….

Answer 61

Follow up

Question 62

what should you do if address changes, name changes, phone number changes, etc. add the date and your initials.

Answer 62

update medical records, one line through, initial