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V.1 > Unit 4: Medical Record Documentation > Flashcards

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

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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

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3
Q

An imaginary plane that extends the length of the body dividing the
body into front and back portions

A

Coronal (frontal) plane

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4
Q

Is the beginning of an extremity or a system

A

Point of origin

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5
Q

Means affecting only one side of the body or one of a pair of body organs

A

Unilateral

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6
Q

Means affecting both sides of the body or both pairs of body organs

A

Bilateral

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7
Q

Movement toward the mid-line of the body

A

Adduction

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8
Q

Movement away from the mid-line of the body

A

Abduction

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9
Q

Movement to close an angle such as the arm movement in a salute

A

Flexion

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10
Q

Movement to open an angle such as reaching out with your arm to turn on a light

A

Extension

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11
Q

Aden

A

Gland

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12
Q

Adip

A

Fat

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13
Q

Ateri/o

A

Artery

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14
Q

Cephal

A

Head

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15
Q

Chondri

A

Cartilage

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16
Q

Cost

A

Rib

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17
Q

Crani

A

Skull

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18
Q

Cyst

A

Bladder

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19
Q

Derma or dermat/o

A

Skin

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20
Q

Duct

A

Tube

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21
Q

Gastr

A

Stomach

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22
Q

Gen

A

To produce

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23
Q

Glossal

A

Tongue

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24
Q

Hepat

A

Liver

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25
Q

Myo

A

Muscle

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26
Q

Nephr/ren

A

Kidney

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27
Q

Neuro

A

Nerve

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28
Q

Opthalm

A

Eye

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29
Q

Oste

A

Bone

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30
Q

Ot

A

Ear

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31
Q

Ov

A

Egg

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32
Q

Thrombo

A

Blood clot

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33
Q

Vas

A

Vessel

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34
Q

A or an

A

Without

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35
Q

Ad

A

To or toward

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36
Q

Ante

A

Before

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37
Q

Bi

A

Two

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38
Q

Bio

A

Life

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39
Q

Epi

A

Upon or on

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40
Q

Inter

A

Between

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41
Q

Intra and endo

A

Within

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42
Q

Erythr/o

A

Red

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43
Q

Hem/o or hemat

A

Blood

44
Q

Hyper

A

Above or an excess

45
Q

Hypo

A

Below or deficient

46
Q

Leuk/o or leuc/o

A

White

47
Q

Peri

A

Around

48
Q

Pneum/o or pneumon/o

A

Refers to air, breath, or lungs

49
Q

Retro

A

Behind

50
Q

Sub

A

Under

51
Q

Algia

A

Pain

52
Q

Blast

A

Forming cell

53
Q

Cyte

A

Cell

54
Q

Ectomy

A

Surgical removal of a part of the body

55
Q

It is

A

Inflammation

56
Q

Logy

A

Study of

57
Q

Osis

A

Condition of

58
Q

Pathy

A

Disease

59
Q

Scopy

A

Visual examination of

60
Q

Stasis

A

Standing still

61
Q

Stenosis

A

Narrowing

62
Q

Tomy

A

Surgical incision

63
Q

q.d.

A

once a day

64
Q

b.i.d.

A

twice a day

65
Q

t.i.d.

A

three times a day

66
Q

q.i.d.

A

four times a day

67
Q

c with a line over it

A

“with”

68
Q

s with a line over it

A

“without”

69
Q

P.O.

A

mouth or orally

70
Q

Hx

A

History

71
Q

c/o or c/c

A

complains of or chief complaint

72
Q

B/P

A

blood pressure

73
Q

S&S

A

signs and symptoms

74
Q

O.S.

A

left eye

75
Q

O.D.

A

right eye

76
Q

R/O

A

rule out

77
Q

Dx

A

diagnosis

78
Q

WNL

A

within normal limits

79
Q

TNTC

A

too numerous to count

80
Q

Moral principles or values held by a group, person, or profession

A

ethics

81
Q

Which AFI covers the release of medical and other personal information?

A

AFI 33–332, The Air Force Privacy and Civil Liberties Program

82
Q

Which office has the official responsibility for releasing medical information?

A

The Patient Administration Office

83
Q

What does a “20” in front of the social security number of Air Force medical records indicate?

A

The record or document belongs to the sponsor

84
Q

What does a “30” in front of the social security number of Air Force medical records indicate?

A

The record or document belongs to the spouse

85
Q

What markings must be on the outside cover of medical records for specific treatments or exposures?

A

Drug allergies, specific treatments such as INH, and specific chemotherapy for cancer

86
Q

What is the most often used form in the medical record?

A

SF Form 600, Chronological Record of Medical Care

87
Q

Which SOAPP entry includes information given from a family member about a patient?

A

Subjective

88
Q

Which SOAPP entry includes laboratory test results?

A

Objective

89
Q

Which SOAPP entry is the professional opinion about the patient’s problem?

A

Assessment

90
Q

Which SOAPP entry is to help solve the patient’s problem?

A

Plan

91
Q

Which SOAPP entry is the strategy to prevent recurrence of the patient’s problem?

A

Prevention

92
Q

Which form will be filled out when there is a potential exposure to rabies?

A

AF Form 2341 Report of Animal Bite – Potential Rabies Exposure

93
Q

Which form will be filled out for Tuberculosis Detection and Control
Data?

A

AF Form 2453

94
Q

Which form will be filled out for Notification of Patient’s Medical Status?

A

AF Form 570

95
Q

The most common way you will receive various laboratory test results is through what system?

A

Composite Health Care System (CHCS)

96
Q

How are abnormal lab tests identified in CHCS?

A

They will be highlighted

97
Q

Which form would you review to find the result of a chest X-ray?

A

SF 519, Radiological Consultation Requests/Reports

98
Q

Which form should accompany a patient being referred to your office for a suspected occupational illness?

A

SF 513, Medical Record - Consultation Sheet

99
Q

Which form is used to record all reference audiograms?

A

DD Form 2215

100
Q

Which form is used if the employee experiences a significant hearing threshold shift, subsequent 15- and 40-hour audiograms are recorded on this form?

A

DD Form 2216

101
Q

Which form is used to request and record further audiologist evaluation: if the patient requires a detailed follow-up?

A

AF Form 1672

102
Q

Which form is completed for civilian workers’ initial occupational medical examinations?

A

SF Form 78, Certificate of Medical Examination

103
Q

Which form is completed for military patients’ initial occupational medical examinations?

A

SF 88, Report of Medical Examination

104
Q

Which form is completed for a patient’s medical history?

A

SF 93, Report of Medical History

105
Q

Which form is completed when workers are exposed to ionizing radiation?

A

AF Form 1527, History of Occupational Exposure to Ionizing Radiation

106
Q

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

A

OEHED, Occupational and Environmental Health Exposure Data Form

107
Q

Which form would you review for a pregnant employee transferring to a new occupational shop?

A

AF Form 469, Duty Limiting Condition Report

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