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Student Clinic Orientation > Final > Flashcards

Final Flashcards

1
Q

A patient has neck, shoulder and knee pain. What OATs are needed?

A

SF-36, QVAS and NDI

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2
Q

After doing a history, you need to get your advising Doc to review and sign off on it before you may start the exam. True or false

A

True

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3
Q

What OATS are needed for neck pain & dizziness?

A

SF-36, QVAS, NDI and DHI

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4
Q

What OATS are needed for low back pain and headaches?

A

SF-36, QVAS, RODI & HDI

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5
Q

When do you use a regional exam?

A

When the patient isn’t responding to care, presents with a new complaint or has extremity pain.

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6
Q

What OATS are needed for a patient with no chief complaint?

A

SF-36

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7
Q

You need DDX, rationale, OATS completed and a doctor’s signature before you can start an exam. True or false

A

True

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8
Q

What does PGIQ stand for?

A

Patient General Information Questionnaire

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9
Q

What does OATS stand for?

A

Outcome assessment tool

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10
Q

When a positive is elicited during an ortho test, what do you need to document?

A

Site, severity and quality of pain

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11
Q

If there’s discrepancy in blood pressure when done bilaterally, what do you do?

A

Make sure you’re using the right sized cuff, retake, and then tell your advising doctor

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12
Q

After an exam or CMR, you need informed consent (true or false)

A

True

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13
Q

What does HHW stand for?

A

Health History Worksheet

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14
Q

What does HIPAA stand for?

A

Health Insurance Portability and Accountability Act

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15
Q

Interns can have open discussion about one another’s patients in the student prep room. True or false.

A

False

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16
Q

CMR?

A
  1. Appointment at records desk
  2. Signed CMR credit form
  3. CMR
  4. Intern case log on N drive
  5. CMR IQA (Intern Qualitative Assessment)
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17
Q

Written permission from a patient allowing the practice to use that patient’s PHI for TPO purposes is what?

A

Consent

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18
Q

The unauthorized acquisition, access, uses or disclosure of PHI which compromises the security or privacy of such information is considered a what?

A

Breach

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19
Q

What is normal specific gravity?

A

Between 1.003 and 1.035

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20
Q

A goal of the US government based on HITECH Act is a certified electronic health record of every US citizen by 2014. True or false?

A

True

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21
Q

The HIPAA privacy rule does not allow a healthcare provider to mail out appointment reminders. True or false

A

False

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22
Q

What is the purpose of the patient history?

A

To collect information, develop a relationship with the patient and educate/motivate the patient

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23
Q

Which of the following is the appropriate method to identify a saved CMR?

A

filenumber.cmr

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24
Q

An intended result of HIPAA was to what?

A

Accountability, privacy, electronic records, simplify billing and implement a big brother nation (really?)

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25
Q

The means by which privacy and confidentiality are ensured?

A

Security

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26
Q

How many systems do you need to cover during the review of systems?

A

10

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27
Q

A ‘no answer’ score on DH is?

A

0

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28
Q

Heart rate, blood pressure and respiration should be done bilaterally. True or false.

A

False.

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29
Q

If your chief complaint is LBP, you still have to do cervical ROM and ortho tests. True or false

A

True

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30
Q

What determines who should have access and patient’s rights to confidentiality and inappropriate access?

A

Privacy

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31
Q

Written permission granted by patient or the patient’s guardian to use or disclose PHI for purposes other than TPO is what?

A

Authorization. NOT consent!

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32
Q

To de-identify a patient record requires the removal of 18 different bits of information. True or false?

A

True

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33
Q

Any release, transfer, provision of access to or divulging in any other manner of protected health information outside the entity holding the information is what?

A

Disclosure

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34
Q

Who is the Life University Compliance Officer responsible for all things HIPAA?

A

Dr. Tim Guest

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35
Q

Life University is designated as a?

A

Hybrid entity

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36
Q

What ist he best doctor/patient orientation for interaction during the history?

A

Facing one another with no furniture between

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37
Q

What ist he purpose of an open-ended question?

A

Leaves discretion to the patient about the extent of the answer

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38
Q

If a patient is in an auto accident and undergoing litigation, they can stay under care at CCHOP. True or false.

A

False!

39
Q

What does SLIDE stand for and what is it used for?

A

Single Line Initial Date new Entry. It’s used for correcting mistakes

40
Q

What determines how the records should be protected from inappropriate access?

A

Confidentiality

41
Q

A subset of health information including demographics collected from an individual is what?

A

Individually Identifiable Health Information

42
Q

What sheet is used for the chief complaint?

A

HHW (health history worksheet)

43
Q

Of the following, what patient information are you allowed to store on personal storage devices?

A

Name and basic contact information such as phone number or email

44
Q

Individually identifiable health information created, maintained or in the possession of the practice relating to the health records and management of a patient is what?

A

Protected health information

45
Q

Under the HITECH changes to HIPAA an employee is not held to the same level of responsibility for PHI breaches as the employer. True or false

A

False

46
Q

Patient present with neck pain. Give 2 related symptoms.

A

Local pain, radiating pain, tingling, numbness, etc.

47
Q

Give an example of an ADL

A

Brushing teeth, getting dressed or showering

48
Q

Anyone who performs or assists in certain functions, activities or services on behalf of the covered entity involving the use or disclosure of individually identifiable health information

A

Business associate

49
Q

What’s in the project?

A

History, exam and CMR

50
Q

HDI deals with physical and emotional headaches… (unsure of question)

A

True

51
Q

What needs to be done to correct an entry?

A

SLIDE (single line date new entry)

52
Q

What ink is allowed in files?

A

Black or blue

53
Q

Patient is not in for 70 days. What is required at next visit?

A

Re-physical

54
Q

What is required before an intern can enter clinic?

A

HIPAA compliance and CPR

55
Q

How often must the intern go to clinic?

A

Minimum of 3x each week to sign in

56
Q

When is RODI used?

A

Back Pain

57
Q

The correct name and password for Opal Rad is

A

aaaa aaaaaaaa or aaa aaaaaaaa

58
Q

To draw a line on the image you click on the arrow in the tool bar…

A

False, that will draw an arrow

59
Q

After acquiring the x-ray study, the intern has how many business days to make their presentation?

A

2 days (or loose the credit)

60
Q

To qualify for toggle films, you must have supine leg length deficiency of 3/16 inch or more and dual probe thermographic scan revealing pattern and thermal asymmetry in the atlas fossa. True or false?

A

True

61
Q

How do you change the contrast of an image?

A

Right mouse button, while in zoom mode & magnifying lens mode

62
Q

How many x-rays are required for 9th quarter?

A

None

63
Q

Postural asymmetry must be noted to qualify for full spine films?

A

True

64
Q

X-ray listings must be documented for all subluxations found on physical exam

A

False

65
Q

Dots required for ilium analysis

A

16

66
Q

Where does the printed CMR summary go?

A

Left side of the file

67
Q

The first step in initiating a new patient process is to have the intern complete the Health Intake Request Form (HIR)?

A

True

68
Q

A “start time” is required before beginning your new patient consultation. True or false

A

True

69
Q

You are required to determine a differential/initial dx based upon patient history and PRIOR to conducting the chiropractic and screening exam

A

True

70
Q

What do you need to add under review of systems in EHR?

A

Emergency contact, immunological/psychological/EENT, and Family history (grandparents)

71
Q

There should be blanks on the green sheets.

A

FALSE. Draw an arrow through the rest of the sheet if you have no tertiary complaints.

72
Q

The history of your new patients secondary complaint is fully documented on which form?

A

Additional Health History worksheet

73
Q

The initial or differential diagnosis should be determined prior to conducting a physical exam for new patients

A

True

74
Q

LU clinics do not accept insurance including medicare and medicaid

A

True

75
Q

SF36…

A

Should be filled out by EVERY patient over the age of 14 years old regardless of complaint at physical and re-physical.

76
Q

RODI…

A

Strictly for LBP. 10 questions with 6 option choices

77
Q

BPI…

A

Back Pain disability index

78
Q

NDI

A

Neck Disability index reserved for neck pain

79
Q

HDI

A

headache disability index

80
Q

QBOX

A

Quadruple visual analog scale, used for any acute pain.

81
Q

On consultation your patient states that she has experienced low back pain in the past but has been asymptomatic for 6 weeks. What’s her chief complaint?

A

Low back pain. Within 90 days is considered current

82
Q

All current musculoskeletal complaints are to be documented on the HHW and AHHW’s using the OPQRST format

A

True

83
Q

At 1st reassessment since initial exam your 19-year-old patient’s chief complaint of severe, acute headaches has resolved. Which OATS must be completed?

A

SF-36, QVAS and HDI

84
Q

A preferred source for creating ADLs would be?

A

OATs

85
Q

The first line of the patient care plan should be updated at beginning of every patient encounter?

A

True

86
Q

To complete the CMR process for credit, what is required of you?

A

Completed note, CMR credit form, intern case log, individual quality assessment

87
Q

Within 48 hours of taking x-rays, (2 business days) the intern must complete the Intern of Radiology Report and review films with the LU radiologist

A

True

88
Q

ICD-9 codes and PC codes can be used interchangeably for documentation purposes

A

False

89
Q

On an initial exam the patient scored a 2% on the HDI. Is another required at the next assessment?

A

Yes

90
Q

“Post findings” and specific date of next visit must be noted in to the assessment speed note

A

False

91
Q

You adjustment findings such as leg checks, static and mopal findings are documented in the objective speed note?

A

True

92
Q

On each routine adjustment visit and IQA (individual quality assessment) is to be opened by the intern and completed by the supervising clinician, even if no adjustment is needed

A

True

93
Q

An explanation is required for any positive ortho, neuro, or ROM test greater than 5 degrees above/below normal?

A

True

94
Q

DHI stands for what?

A

Dizziness handicap inventory

Student Clinic Orientation (2 decks)

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