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 plane
Is the beginning of an extremity or a system
Point of
origin
Directional terms associated with the point of origin are
proximal and distal
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
Moral principles or values held by a group, person, or profession
ethics
The established standards of behavior to be followed by everybody within a specific group, such as the
health care professions
ethical behavior
Which Air Force instruction (AFI) covers the release of medical and other personal information?
AFI 33–332, Air Force Privacy and Civil Liberties Program
Health records are the property of the
United States government
The prefix “20” in front of a social security number on a medical record indicates the record is for the
sponsor
The prefix “30” in front of a social security number on a medical record indicates the record is for the
spouse
The prefix “01” and so on in front of a social security number on a medical record indicates the record is for the
first child
How should a patient’s medical record indicate he or she has drug allergies?
Outside of the record should be marked
What does SOAPP stand for?
subjective, objective, assessment, plan, and prevention
Which form should you review to determine the particular duty restrictions of a military worker?
AF Form 469, Duty Limiting Condition Report
Workers assigned to hazardous work areas surveyed by BE have this form placed in their medical records
OEHED, Occupational and Environmental Health Exposure Data Form
This form is used when one medical section needs the expertise of another medical section
SF 513, Medical Record -Consultation Sheet
Review this form for patients either suspected of active tuberculosis or who were exposed to a person with active tuberculosis
SF 519B, Radiologic Consultation Request/Reports
A physician who suspects an occupational illness or an occupational injury with chronic health
consequences refers patients to PH for interview with an
SF Form 513
Used to record all reference audiograms
DD Form 2215
If the employee experiences a significant hearing threshold shift, subsequent 15- and 40-hour audiograms are recorded on this form
DD Form 2216
Used to request and record further audiologist evaluation: if the patient requires a detailed follow-up
AF Form 1672
Completed for civilian workers’ initial occupational medical examinations
SF Form 78
Is completed for military patients’ initial
occupational medical examinations
SF 88, Report of Medical Examination
Patients who provide a complete medical history do so on this form
SF 93, Report of Medical History
Workers exposed
to ionizing radiation will complete this form
AF Form 1527, History of Occupational Exposure to Ionizing Radiation
