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Chapter 1 questions

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What are the functions of the medical record?
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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.
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What is the meaning of HIPAA?
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Health Insurance Portability and Accountability Act.
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What is the purpose of the HIPAA Privacy Rule?
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To provide patients with better control over the use and disclosure of their health information.
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Who must comply with HIPAA?
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All healthcare providers, health plans and heath care, clearinghouses that use, store, maintain, or transmit health information.
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What is a Notice of Privacy Practices?
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An explanation to patients of how their protected health information (PMI) will be used and protected by the medical office.
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Give examples of when HIPAA does not require written consent for the use or disclosure of a patient’s health information.
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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.
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What two general categories of information are included on a patient registration record?
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Demographic information and billing information.
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What are three uses of the health history?
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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.
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What is the purpose of the physical examination?
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To provide objective data about a patient, which assists the physician in determining the patient’s state of health.
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What is the purpose of progress notes?
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To document the patient’s health status from one visit to the next.
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What are the three categories of medications that may be included in a medication record?
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Prescription medications. Over-the-counter medications. Medications administered at the medical office.
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What is the purpose of home heath care?
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To minimize the effect of disease or disability by promoting, maintaining and restoring the patient’s health.
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Give examples of home health care services.
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Cardiac home care, IV (intravenous) Therapy, respiratory therapy, pain management, diabetes management, rehabilitation, maternal-child care.
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What is the purpose of a laboratory report?
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To relay the results of laboratory tests to the physician to assist in diagnosing and treating disease.
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Give examples of diagnostic procedure reports.
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Electrocardiogram reports, Holter monitor reports, Sigmoidoscopy reports, colonscopy reports, Spirometry reports, Radiology reports, Diagnostic imaging reports.
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What is the purpose of the therapeutic service report?
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To document the assessments and treatments designed to restore a patient’s ability to function.
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What is the difference between physical therapy and occupational therapy?
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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.
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Give examples of physical agents used in physical therapy.
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Therapeutic exercise, thermal modalities, cold, hydrotherapy, massage, electrical stimulation.
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What is speech therapy?
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Treatment for the correction of a speech impairment resulting from birth, disease,injury, or previous medical treatment.
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What is the purpose of an operative report?
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To describe the surgical procedure and technique used during the procedure.
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What is the purpose of the discharge summary report?
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To document information needed by the patient’s physician to provide for the continuity of future care.
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What is included in a pathology report?
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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.
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Why is a copy of the emergency room report sent to the patient’s family physician?
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For the purpose of providing followup care.
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When is a consent to treatment form required?
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For all surgical operations and nonroutine therapeutic and diagnostic procedures performed in the medical office.
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What is the purpose of a consent to treatment form?
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To document that the patient agrees to the procedure listed on the form.
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What information must the patient receive before signing a consent to treatment form?
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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.
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What does witnessing a signature mean? What does it not mean?
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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.
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When must a patient complete a release of information form?
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When moving to another state and wants to transfer his or her medical record to a new physician.
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When does a release of medical information form not have to be completed?
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For the purpose of medical treatment, payment and health care operation (TPO).
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What is the difference between a PPR and EMR?
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PPR is paper based record. EMR is electronic medical record.
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What functions are performed by an EMR software program?
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Creating, storing and organization of a record.
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What are the advantages of the electronic medical record?
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Speed and productivity, efficiency and accessibility.
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How are paper documents entered into a patient’s electronic medical record?
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They are scanned in or the medical assistant enters the information manually.
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How are documents organized in a source-oriented medical record?
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Organized into sections based on the department, facility or other source that generated the information.
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How are documents organized in a problem-oriented medical record (POR)?
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Organized according to the patient’s health problems.
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List four parts of a POR?
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Establish a database. Compile a problem list. Devise a plan of action for each problem. Follow each problem with progress notes.
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What is the format used to organize progress notes?
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Begin with the number of the problem, subjective data obtained from the patient, objective data obtained by observation, assessment and plan.
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How can a health history be entered in the EMR?
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Manually by the MA either taken from paper form or by asking the patient directly.
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What are the seven parts of the health history?
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Identification data (basic demographic information). Chief complaint. Present illness. Past history. Family history. Social history. Review of systems.
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What is a chief complaint?
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The reason for seeking care.
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What guidelines should be followed in recording the chief complaint?
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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.
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What is the current illness, and how is this information obtained?
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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.
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Give examples of information included in the past medical history.
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Major illness, childhood diseases, unusual infections, accidents and injuries, hospitalizations and operations, previous medical tests, immunizations, allergies, current medications.
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Give three examples of familial diseases.
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Hypertension, heart disease, allergies, diabetes.
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What is the importance of the social history?
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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.
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What is the purpose of the review of systems (ROS)?
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It assists in identifying symptoms that might otherwise remain undetected.
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What guidelines should be followed to ensure accurate and concise charting?
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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.
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Give examples of objective symptoms.
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Rash, coughing, cyanosis.
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What information is protected by law and cannot be released unless specifically authorized by the patient?
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Drug abuse diagnosis and treatment, Alcoholism diagnosis and treatment, Mental Health diagnosis and treatment, and Sexually Transmitted Diseases.
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Give reasons why a patient may authorize the release of his or her medical record.
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Moving to another state. Taking to another doctor. Legal purpose. Insurance purpose. Worker’s compensation.
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What must the patient do if he or she wants to revoke the authorization?
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Notify the medical office in writing.