Chapter 8-10

Question 1

Commercial filing system

Answer 1

Alphabetical and or numerical which uses folders and guides manufactured for professional office use medical and financial records are filed separately

Question 2

Data bases

Answer 2

Electronic files or databases are used in the medical practices to store a collection of information electronically … May consist of files pertaining to patients drugs , diagnosis procedures diseases surgeries or other categories

Question 3

Encryption

Answer 3

A secure form of retaining confidentiality is a software program that stores files in coded form

Question 4

Destroying documents

Answer 4

Shredders ,

Stand alone machines

Question 5

Medical record

Answer 5

Is a handwritten or type written recording of information that documents facts and events during the administration of patient care
It contains sensitive personal information and tells the story starting with the patient’s medical history

Question 6

Examples of medical records

Answer 6

Track patient histories prescription drugs consultations and a variety of data

Question 7

EHR

Electronic health record

Answer 7

Everything goes electronic including patient records and the ability to communicate with other systems also out of the office

Question 8

Medical record organization system

Answer 8

Problem oriented medical record
Source oriented record
integrated record

Question 9

Problem oriented medical record(POMR)

Answer 9

A form that includes identification data and lists in tabular form all of the patients permanent and temporary problems each one numbered and dated

Question 10

Source oriented record (SOR)

Answer 10

Paper based management system
Documents are arranged according to sections for example history and physical section progress notes surgical operations . Color laminated tab dividers
Chronological order
Most recent on top

Question 11

Integrated record system

Answer 11

Files or documents in chronological order without regard to their source

Question 12

Record keeping

Answer 12

Physician hand enters data
Physician dictates
Physician keys data
Medical assistant enters data

Question 13

4 type of physicians

Answer 13

Attending physician 
Consulting physician 
ordering physician 
Referring physician
Treating or performing physician

Question 14

Chief complaint

Answer 14

Symptoms

Usually subjective

Question 15

Diagnosis

Answer 15

An impression, assessment or final conclusion of the nature of the disease or illness based on history physical examination findings and tests

Question 16

Prognosis

Answer 16

A probable outcome of the disease or injury and the prospect of recovering. it includes an estimate of partial or total disability in an accident or industrial case

Question 17

Abstract

Answer 17

To take out specific information or to summarize from documentation in a patients chart

Question 18

Audit

Answer 18

Periodically examine or review a group of patient records , purpose is to verify that good record keeping is in place

Question 19

(DEA)

Drug enforcement administration

Answer 19

Regulates the manufacturing and dispensing of dangerous and potentially abused drugs

Question 20

Drug names

Answer 20

Brand name
Chemical name
Generic name

Question 21

E - prescribing

Answer 21

Electronic prescription

Question 22

Pharmacist

Answer 22

Person with degree that is skilled in the art or practice of preparing preserving , compounding and dispensing drugs, a druggist