Chapter 1 questions – Flashcards
Unlock all answers in this set
Unlock answersquestion
What are the functions of the medical record?
answer
Information in the medical record is used as a basis for decision regarding patient care and treatment. Documents the results of treatment and patient progress. Provides an efficient and effective method by which information can be communicated to authorized personnel.
question
What is the meaning of HIPAA?
answer
Health Insurance Portability and Accountability Act.
question
What is the purpose of the HIPAA Privacy Rule?
answer
To provide patients with better control over the use and disclosure of their health information.
question
Who must comply with HIPAA?
answer
All healthcare providers, health plans and heath care, clearinghouses that use, store, maintain, or transmit health information.
question
What is a Notice of Privacy Practices?
answer
An explanation to patients of how their protected health information (PMI) will be used and protected by the medical office.
question
Give examples of when HIPAA does not require written consent for the use or disclosure of a patient's health information.
answer
Treatment: Patient referral to a specialist, emergency room care provided at a hospital. Payment: Determination of eligibility for insurance benefits. Health care operations: Quality assessment activities, training of health care students.
question
What two general categories of information are included on a patient registration record?
answer
Demographic information and billing information.
question
What are three uses of the health history?
answer
To determine the patient's general state of heath. To arrive at a diagnosis and to prescribe treatment. To document any change in a patient's illness after treatment has been instituted.
question
What is the purpose of the physical examination?
answer
To provide objective data about a patient, which assists the physician in determining the patient's state of health.
question
What is the purpose of progress notes?
answer
To document the patient's health status from one visit to the next.
question
What are the three categories of medications that may be included in a medication record?
answer
Prescription medications. Over-the-counter medications. Medications administered at the medical office.
question
What is the purpose of home heath care?
answer
To minimize the effect of disease or disability by promoting, maintaining and restoring the patient's health.
question
Give examples of home health care services.
answer
Cardiac home care, IV (intravenous) Therapy, respiratory therapy, pain management, diabetes management, rehabilitation, maternal-child care.
question
What is the purpose of a laboratory report?
answer
To relay the results of laboratory tests to the physician to assist in diagnosing and treating disease.
question
Give examples of diagnostic procedure reports.
answer
Electrocardiogram reports, Holter monitor reports, Sigmoidoscopy reports, colonscopy reports, Spirometry reports, Radiology reports, Diagnostic imaging reports.
question
What is the purpose of the therapeutic service report?
answer
To document the assessments and treatments designed to restore a patient's ability to function.
question
What is the difference between physical therapy and occupational therapy?
answer
Physical therapy--Restore function and promote healing after an injury. Occupational therapy--To learn a new skill to adapt to a physically, developmentally, emotionally, or mentally disabling condition.
question
Give examples of physical agents used in physical therapy.
answer
Therapeutic exercise, thermal modalities, cold, hydrotherapy, massage, electrical stimulation.
question
What is speech therapy?
answer
Treatment for the correction of a speech impairment resulting from birth, disease,injury, or previous medical treatment.
question
What is the purpose of an operative report?
answer
To describe the surgical procedure and technique used during the procedure.
question
What is the purpose of the discharge summary report?
answer
To document information needed by the patient's physician to provide for the continuity of future care.
question
What is included in a pathology report?
answer
Information about the size, shape and appearance of a specimen as it appears to the naked eye and includes a diagnosis of the patient's condition.
question
Why is a copy of the emergency room report sent to the patient's family physician?
answer
For the purpose of providing followup care.
question
When is a consent to treatment form required?
answer
For all surgical operations and nonroutine therapeutic and diagnostic procedures performed in the medical office.
question
What is the purpose of a consent to treatment form?
answer
To document that the patient agrees to the procedure listed on the form.
question
What information must the patient receive before signing a consent to treatment form?
answer
The nature of the condition, the nature and purpose of the recommended procedure,explanation of risks involved, alternative treatments or procedures, likely outcome of the procedure, risks of declining or delaying the procedure.
question
What does witnessing a signature mean? What does it not mean?
answer
Means that the medical assistant has verified the patient's identity and watched the patient sign the form. Not mean--attesting to the accuracy of the information provided.
question
When must a patient complete a release of information form?
answer
When moving to another state and wants to transfer his or her medical record to a new physician.
question
When does a release of medical information form not have to be completed?
answer
For the purpose of medical treatment, payment and health care operation (TPO).
question
What is the difference between a PPR and EMR?
answer
PPR is paper based record. EMR is electronic medical record.
question
What functions are performed by an EMR software program?
answer
Creating, storing and organization of a record.
question
What are the advantages of the electronic medical record?
answer
Speed and productivity, efficiency and accessibility.
question
How are paper documents entered into a patient's electronic medical record?
answer
They are scanned in or the medical assistant enters the information manually.
question
How are documents organized in a source-oriented medical record?
answer
Organized into sections based on the department, facility or other source that generated the information.
question
How are documents organized in a problem-oriented medical record (POR)?
answer
Organized according to the patient's health problems.
question
List four parts of a POR?
answer
Establish a database. Compile a problem list. Devise a plan of action for each problem. Follow each problem with progress notes.
question
What is the format used to organize progress notes?
answer
Begin with the number of the problem, subjective data obtained from the patient, objective data obtained by observation, assessment and plan.
question
How can a health history be entered in the EMR?
answer
Manually by the MA either taken from paper form or by asking the patient directly.
question
What are the seven parts of the health history?
answer
Identification data (basic demographic information). Chief complaint. Present illness. Past history. Family history. Social history. Review of systems.
question
What is a chief complaint?
answer
The reason for seeking care.
question
What guidelines should be followed in recording the chief complaint?
answer
Ask open-ended questions, should be limited to 1 or 2 symptoms and be specific, record concisely and briefing, use the patient's own words, duration of symptoms, avoid using names of diseases or diagnostic terms.
question
What is the current illness, and how is this information obtained?
answer
An expansion of the chief complaint and includes a full description of the patient's current illness from the time of onset. The MA asks open-ended questions.
question
Give examples of information included in the past medical history.
answer
Major illness, childhood diseases, unusual infections, accidents and injuries, hospitalizations and operations, previous medical tests, immunizations, allergies, current medications.
question
Give three examples of familial diseases.
answer
Hypertension, heart disease, allergies, diabetes.
question
What is the importance of the social history?
answer
The patient's lifestyle may influence the course of treatment chosen by the physician and the effect that the illness may have on the patient's daily living pattern.
question
What is the purpose of the review of systems (ROS)?
answer
It assists in identifying symptoms that might otherwise remain undetected.
question
What guidelines should be followed to ensure accurate and concise charting?
answer
Check the name on the chart before making an entry to ensure you have the correct chart. Use black ink to make entries in the patent's chart. Write using legible handwriting. Chart information accurately, using clear and concise phrases. Chart immediately after performing a procedure. Each entry should be signed by the person making it. Never erase or obliterate an entry.
question
Give examples of objective symptoms.
answer
Rash, coughing, cyanosis.
question
What information is protected by law and cannot be released unless specifically authorized by the patient?
answer
Drug abuse diagnosis and treatment, Alcoholism diagnosis and treatment, Mental Health diagnosis and treatment, and Sexually Transmitted Diseases.
question
Give reasons why a patient may authorize the release of his or her medical record.
answer
Moving to another state. Taking to another doctor. Legal purpose. Insurance purpose. Worker's compensation.
question
What must the patient do if he or she wants to revoke the authorization?
answer
Notify the medical office in writing.
