Unit 4: Medical Record Documentation Flashcards
An imaginary plane that extends the length of the body, dividing it into equal right and left portions.
Mid-sagittal plane
An imaginary plane that extends the width of any portion of the body dividing it into upper and lower portions
Transverse plane
An imaginary plane that extends the length of the body dividing the
body into front and back portions
Coronal (frontal) plane
Is the beginning of an extremity or a system
Point of origin
Means affecting only one side of the body or one of a pair of body organs
Unilateral
Means affecting both sides of the body or both pairs of body organs
Bilateral
Movement toward the mid-line of the body
Adduction
Movement away from the mid-line of the body
Abduction
Movement to close an angle such as the arm movement in a salute
Flexion
Movement to open an angle such as reaching out with your arm to turn on a light
Extension
Aden
Gland
Adip
Fat
Ateri/o
Artery
Cephal
Head
Chondri
Cartilage
Cost
Rib
Crani
Skull
Cyst
Bladder
Derma or dermat/o
Skin
Duct
Tube
Gastr
Stomach
Gen
To produce
Glossal
Tongue
Hepat
Liver
Myo
Muscle
Nephr/ren
Kidney
Neuro
Nerve
Opthalm
Eye
Oste
Bone
Ot
Ear
Ov
Egg
Thrombo
Blood clot
Vas
Vessel
A or an
Without
Ad
To or toward
Ante
Before
Bi
Two
Bio
Life
Epi
Upon or on
Inter
Between
Intra and endo
Within
Erythr/o
Red
Hem/o or hemat
Blood
Hyper
Above or an excess
Hypo
Below or deficient
Leuk/o or leuc/o
White
Peri
Around
Pneum/o or pneumon/o
Refers to air, breath, or lungs
Retro
Behind
Sub
Under
Algia
Pain
Blast
Forming cell
Cyte
Cell
Ectomy
Surgical removal of a part of the body
It is
Inflammation
Logy
Study of
Osis
Condition of
Pathy
Disease
Scopy
Visual examination of
Stasis
Standing still
Stenosis
Narrowing
Tomy
Surgical incision
q.d.
once a day
b.i.d.
twice a day
t.i.d.
three times a day
q.i.d.
four times a day
c with a line over it
“with”
s with a line over it
“without”
P.O.
mouth or orally
Hx
History
c/o or c/c
complains of or chief complaint
B/P
blood pressure
S&S
signs and symptoms
O.S.
left eye
O.D.
right eye
R/O
rule out
Dx
diagnosis
WNL
within normal limits
TNTC
too numerous to count
Moral principles or values held by a group, person, or profession
ethics
Which AFI covers the release of medical and other personal information?
AFI 33–332, The Air Force Privacy and Civil Liberties Program
Which office has the official responsibility for releasing medical information?
The Patient Administration Office
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
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
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
What is the most often used form in the medical record?
SF Form 600, Chronological Record of Medical Care
Which SOAPP entry includes information given from a family member about a patient?
Subjective
Which SOAPP entry includes laboratory test results?
Objective
Which SOAPP entry is the professional opinion about the patient’s problem?
Assessment
Which SOAPP entry is to help solve the patient’s problem?
Plan
Which SOAPP entry is the strategy to prevent recurrence of the patient’s problem?
Prevention
Which form will be filled out when there is a potential exposure to rabies?
AF Form 2341 Report of Animal Bite – Potential Rabies Exposure
Which form will be filled out for Tuberculosis Detection and Control
Data?
AF Form 2453
Which form will be filled out for Notification of Patient’s Medical Status?
AF Form 570
The most common way you will receive various laboratory test results is through what system?
Composite Health Care System (CHCS)
How are abnormal lab tests identified in CHCS?
They will be highlighted
Which form would you review to find the result of a chest X-ray?
SF 519, Radiological Consultation Requests/Reports
Which form should accompany a patient being referred to your office for a suspected occupational illness?
SF 513, Medical Record - Consultation Sheet
Which form is used to record all reference audiograms?
DD Form 2215
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
Which form is used to request and record further audiologist evaluation: if the patient requires a detailed follow-up?
AF Form 1672
Which form is completed for civilian workers’ initial occupational medical examinations?
SF Form 78, Certificate of Medical Examination
Which form is completed for military patients’ initial occupational medical examinations?
SF 88, Report of Medical Examination
Which form is completed for a patient’s medical history?
SF 93, Report of Medical History
Which form is completed when workers are exposed to ionizing radiation?
AF Form 1527, History of Occupational Exposure to Ionizing Radiation
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
Which form would you review for a pregnant employee transferring to a new occupational shop?
AF Form 469, Duty Limiting Condition Report
