Unit 4: Medical Record Documentation Flashcards
1
Q
An imaginary plane that extends the length of the body, dividing it into equal right and left portions.
A
Mid-sagittal plane
2
Q
An imaginary plane that extends the width of any portion of the body dividing it into upper and lower portions
A
Transverse plane
3
Q
An imaginary plane that extends the length of the body dividing the
body into front and back portions
A
Coronal (frontal) plane
4
Q
Is the beginning of an extremity or a system
A
Point of origin
5
Q
Means affecting only one side of the body or one of a pair of body organs
A
Unilateral
6
Q
Means affecting both sides of the body or both pairs of body organs
A
Bilateral
7
Q
Movement toward the mid-line of the body
A
Adduction
8
Q
Movement away from the mid-line of the body
A
Abduction
9
Q
Movement to close an angle such as the arm movement in a salute
A
Flexion
10
Q
Movement to open an angle such as reaching out with your arm to turn on a light
A
Extension
11
Q
Aden
A
Gland
12
Q
Adip
A
Fat
13
Q
Ateri/o
A
Artery
14
Q
Cephal
A
Head
15
Q
Chondri
A
Cartilage
16
Q
Cost
A
Rib
17
Q
Crani
A
Skull
18
Q
Cyst
A
Bladder
19
Q
Derma or dermat/o
A
Skin
20
Q
Duct
A
Tube
21
Q
Gastr
A
Stomach
22
Q
Gen
A
To produce
23
Q
Glossal
A
Tongue
24
Q
Hepat
A
Liver
25
Myo
Muscle
26
Nephr/ren
Kidney
27
Neuro
Nerve
28
Opthalm
Eye
29
Oste
Bone
30
Ot
Ear
31
Ov
Egg
32
Thrombo
Blood clot
33
Vas
Vessel
34
A or an
Without
35
Ad
To or toward
36
Ante
Before
37
Bi
Two
38
Bio
Life
39
Epi
Upon or on
40
Inter
Between
41
Intra and endo
Within
42
Erythr/o
Red
43
Hem/o or hemat
Blood
44
Hyper
Above or an excess
45
Hypo
Below or deficient
46
Leuk/o or leuc/o
White
47
Peri
Around
48
Pneum/o or pneumon/o
Refers to air, breath, or lungs
49
Retro
Behind
50
Sub
Under
51
Algia
Pain
52
Blast
Forming cell
53
Cyte
Cell
54
Ectomy
Surgical removal of a part of the body
55
It is
Inflammation
56
Logy
Study of
57
Osis
Condition of
58
Pathy
Disease
59
Scopy
Visual examination of
60
Stasis
Standing still
61
Stenosis
Narrowing
62
Tomy
Surgical incision
63
q.d.
once a day
64
b.i.d.
twice a day
65
t.i.d.
three times a day
66
q.i.d.
four times a day
67
c with a line over it
"with"
68
s with a line over it
"without"
69
P.O.
mouth or orally
70
Hx
History
71
c/o or c/c
complains of or chief complaint
72
B/P
blood pressure
73
S&S
signs and symptoms
74
O.S.
left eye
75
O.D.
right eye
76
R/O
rule out
77
Dx
diagnosis
78
WNL
within normal limits
79
TNTC
too numerous to count
80
Moral principles or values held by a group, person, or profession
ethics
81
Which AFI covers the release of medical and other personal information?
AFI 33–332, The Air Force Privacy and Civil Liberties Program
82
Which office has the official responsibility for releasing medical information?
The Patient Administration Office
83
What does a “20” in front of the social security number of Air Force medical records indicate?
The record or document belongs to the sponsor
84
What does a “30” in front of the social security number of Air Force medical records indicate?
The record or document belongs to the spouse
85
What markings must be on the outside cover of medical records for specific treatments or exposures?
Drug allergies, specific treatments such as INH, and specific chemotherapy for cancer
86
What is the most often used form in the medical record?
SF Form 600, Chronological Record of Medical Care
87
Which SOAPP entry includes information given from a family member about a patient?
Subjective
88
Which SOAPP entry includes laboratory test results?
Objective
89
Which SOAPP entry is the professional opinion about the patient’s problem?
Assessment
90
Which SOAPP entry is to help solve the patient’s problem?
Plan
91
Which SOAPP entry is the strategy to prevent recurrence of the patient’s problem?
Prevention
92
Which form will be filled out when there is a potential exposure to rabies?
AF Form 2341 Report of Animal Bite – Potential Rabies Exposure
93
Which form will be filled out for Tuberculosis Detection and Control
Data?
AF Form 2453
94
Which form will be filled out for Notification of Patient’s Medical Status?
AF Form 570
95
The most common way you will receive various laboratory test results is through what system?
Composite Health Care System (CHCS)
96
How are abnormal lab tests identified in CHCS?
They will be highlighted
97
Which form would you review to find the result of a chest X-ray?
SF 519, Radiological Consultation Requests/Reports
98
Which form should accompany a patient being referred to your office for a suspected occupational illness?
SF 513, Medical Record - Consultation Sheet
99
Which form is used to record all reference audiograms?
DD Form 2215
100
Which form is used if the employee experiences a significant hearing threshold shift, subsequent 15- and 40-hour audiograms are recorded on this form?
DD Form 2216
101
Which form is used to request and record further audiologist evaluation: if the patient requires a detailed follow-up?
AF Form 1672
102
Which form is completed for civilian workers’ initial occupational medical examinations?
SF Form 78, Certificate of Medical Examination
103
Which form is completed for military patients’ initial occupational medical examinations?
SF 88, Report of Medical Examination
104
Which form is completed for a patient's medical history?
SF 93, Report of Medical History
105
Which form is completed when workers are exposed to ionizing radiation?
AF Form 1527, History of Occupational Exposure to Ionizing Radiation
106
Workers assigned to hazardous work areas surveyed by BE have this form placed in their medical records
Exception: those workplaces whose only exposure is to hazardous noise
OEHED, Occupational and Environmental Health Exposure Data Form
107
Which form would you review for a pregnant employee transferring to a new occupational shop?
AF Form 469, Duty Limiting Condition Report
