Evaluation Of Learning

Question 1

Three functions of the medical record

Answer 1

1. Basis for decisions regarding the patients care and treatment.
2. Provides an efficient and effective method by which information can be communicated to authorized personnel on the medical office.
3. Serves as a legal document.

Question 2

The two most common types of medical records

Answer 2

Paper based patient record

Electronic medical record

Question 3

Describe source orientated record format

Answer 3

It is organized into sections based on the department, facility, or other source generated the information.

Question 4

Describe problem orientated record format

Answer 4

Organized according to the patients health problems. 
Developed in 4 stages. 
 Data base 
 Problem list
 Plan 
 Progress notes

Question 5

Two general categories of information that are included on a patient registration record

Answer 5

Demographics

Billing information

Question 6

When is a procedure consent form required?

Answer 6

For all surgical operations and nonroutine therapeutic and diagnostic procedures performed in the medical office.

Question 7

What is an advantage of the EMR related to allergies?

Answer 7

It’s ability to cross check allergies with new medications that might be ordered, including immunizations

Question 8

3 categories of medication that may be included in medication record

Answer 8

Prescription
OTC
Medications administered at the medical office such as natural remedies , immunizations

Question 9

5 examples of home health services

Answer 9

Cardiac home care
Intravenous therapy 
Respiratory therapy 
Pain management 
Diabetes management

Question 10

Purpose of therapeutic service report

Answer 10

It documents the assessment and treatments designed to restore a patients ability to function