Week 1

Question 1

information that is gained from the patient

Answer 1

Subjective data

Question 2

What is cc?

What information is needed when describing the patients cc?

Answer 2

Chief Complaint; documented information using the patient’s own words.

The main reason for a patient’s visit, use quotation marks, the duration of the pain, when the symptoms started, remedies they’ve used, etc.

Question 3

Continuity of care:

Answer 3

The smooth continuation of care from one provider to another allow the patient to receive the most benefit, and with no interruption or duplication of care

Question 4

Why is it important to keep accurate medical records

Answer 4

Proof for a legal defense
Money
High-quality of care
Track vital statistics

Question 5

What information belongs in the “Objective” section

Answer 5

sign, something that is measured or observed by others. (Edema)

Question 6

How can medical records be released?

Answer 6

Written release from the patient

Question 7

Medical office will keep health records of a minor until they

Answer 7

Until the minor reaches the age of majority plus the statute of limitations

Question 8

is used the most when a follow-up with a patient is needed

Question 9

are for patients that have passed away, moved away or terminated their relationships with a physician

Answer 9

Closed Records

Question 10

Process of moving an active file to inactive is called

Answer 10

Purging

Question 11

Medical records are property of the

Answer 11

Physician or provider

Question 12

How do you properly correct an error in a paper chart?

Answer 12

Put a line through it and put your initials

Question 13

Explain what color-coding filing system is

Answer 13

A specific color is selected to identify each letter of the alphabet or number. For instance, a specific color may be used for all paper health records beginning with the same letter

Question 14

is the type of electronic records that are used in individual practices

Answer 14

EMR = Electronic medical record

Question 15

Describe to me how to make a correction in a EHR program:

Answer 15

With an addendum with the current date and time

Question 16

PHR means

Answer 16

Personal health record; as an electronic record of health-related information about an individual

Question 17

Explain the term “vested”

Answer 17

Granted or endowed with a particular authority, right, or property; to have a special interest in.

Question 18

Explain Alphanumeric filing:

Answer 18

A system that uses letters and numbers

Question 19

EHR systems are updated

Question 20

POMR mean
what are the 4 components

Answer 20

Problem-oriented medical record

Database, problem list, treatment plan, and progress notes

Question 21

Particular group of vocabulary is known as

Answer 21

cluster

Question 22

Describe what being an “active listening” is

Answer 22

Listening carefully to the other person, picking up on the nonverbal cues, ( tone of voice, and rate of speech) ask questions, listen insensitively, do not cut them off while they’re talking, and restate what they say

Question 23

What are appropriate calls that can be made from the office

Question 24

The depth of a sound is known as

Answer 24

The pitch

Question 25

Articulation of sounds is known as

Answer 25

Articulatory phonetics

Question 26

What professional term means “Professional Jargon”

Answer 26

Medical terminology

Question 27

How can you create a positive impression over the phone?

Answer 27

Smile

Question 28

When answering the phone at your office, what should be the first thing that the caller hears?

Answer 28

The Facility name, your name and how may I help you?

Question 29

An ______ _______ are considered urgent, but not an emergency.

Answer 29

• Minor burns and cuts (with limited bleeding)
• Fever, influenza, cough, ear pain, and sore throat
• Mild to moderate breathing difficulties
• Urinary tract infection symptoms
• Digestive system symptoms such as vomiting, diarrhea, and dehydration
• Orthopedic concerns, such as sprains, strains, and minor broken bones (e.g., fingers, toes, and arms

Question 30

Callers should not be on hold longer than

Answer 30

no longer than 1 minute before the medical assistant checks back with the person.

Question 31

MA’s may give test results, depending on the following circumstances

Answer 31

The provider decides whether the medical assistant can relay the results or the provider needs to speak to the patient directly.

Question 32

Answering services are used for

Answer 32

After office hours, most healthcare facilities use an answering service or an answering machine that directs the caller to the answering service if there is an urgent issue.

Question 33

What types of out-patient procedures can we possible schedule for a patient

Answer 33

Colonoscopy, magnetic resonance imaging (MRI), and computed tomography (CT) scans

Question 34

is when a person fails to arrive for their scheduled appointment

Answer 34

no-show

Question 35

If a patient needs a series of appointments, what is the best thing to do

Answer 35

it is best to schedule the appointments on the same day of the week and at the same time. This will help the patient remember them more easily.

Question 36

Explain what “Self-Scheduling” is

Answer 36

Self-scheduling allows the patient to schedule an appointment online using the patient portal or facility’s website. Patients can schedule at any time of the day or night, without the assistance of the ambulatory care staff.

Question 37

Explain what “ Wave Scheduling” is:

Answer 37

Wave scheduling is an attempt to create flexibility within each hour. Wave scheduling assumes that the actual time needed for all the patients seen will average out over the course of the day. With wave scheduling, three patients are given the same appointment time. They are then seen in the order of their arrival. This way, one person’s late arrival does not disrupt the entire schedule.

Question 38

Explain what “ Open-office hours” scheduling is:

Answer 38

The patients are told that they can come in at any time. This type of system is often used in an urgent care setting. Patients are seen in the order in which they arrive, although patients with urgent conditions may be given priority.

Question 39

When a patient needs to reschedule, what are the two things we should do?

Answer 39

make sure the first appointment is removed from the appointment book and then set the new appointment.

Question 40

If a patient “No-Call, No-shows” for their appointment, what should be done?

Answer 40

Must be documented in the schedule and in the patient’s health record.

It is important to determine the reason for failed appointments and to do whatever is possible to remedy the situation

Question 41

PHI means

Answer 41

protected health information (PHI) Individually identifiable health information stored or transmitted by covered entities or business associates; includes verbal, paper, or electronic information.