question

The medical record serves as a legal document.

answer

True

question

The purpose of progress notes is to update the medical record with new information.

answer

True

question

The patient registration record consists of a list of the problems associated with the patient's illness.

answer

False - Patient registration record consists of demographic and billing information.

question

All OTC medications taken by the patient should be charted on the medication record form.

answer

True

question

A consultation report is a narrative report of a clinical opinion about a patient's condition by a practitioner other than the primary physician.

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True

question

A report of the analysis of body specimens is known as a diagnostic report.

answer

False - A Laboratory report

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Medical impressions are conclusions drawn from an interpretation of data.

answer

True

question

A consent to treatment form is required for tuberculin skin testing.

answer

False - Consent to treatment forms are required for all surgical operations and non routine therapeutic and diagnostic procedures.

question

Diabetes mellitus is an example of a familial disease.

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True

question

Pain is an example of an objective symptom.

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False - pain would be subjective symptom because it is felt by the patient and cannot be observed by another person

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The purpose of HIPAA is to provide patients with more control over the use and disclosure of their health information.

answer

True

question

The health history provides subjective data about a patient to assist the physician in arriving at a diagnosis.

answer

True

question

Physical therapy helps a patient with a disability learn new skills to perform the activities of daily living.

answer

False - this refers to occupational therapy physical therapy helps to promote healing after and illness or injury.

question

A copy of the patient's emergency room report is sent to the patient's family physician.

answer

True

question

When a medical assistant witnesses a patient's signature on a form, it means that the medical assistant is verifying that the patient understands the information on the form.

answer

False - witnessing a signature means only that the medical assistant verified the patient's identity and watched the patient sign the form

question

SOAP is the acronym for the format used to organize POR progress notes.

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True

question

The chief complaint is the symptom causing the patient the most trouble.

answer

True

question

The social history includes information on the patient's lifestyle, such as health habits and living environment.

answer

True

question

The patient's name must be included at the beginning of each entry charted in the patient's medical record.

answer

False

question

A decrease in the amount of water in the body is known as edema.

answer

False - Edema is the retention of fluids in the tissue, resulting in swelling.

question

Attending Physician

answer

The physician responsible for the care of a hospitalized patient.

question

Chartting

answer

The process of documenting information about a patient in the medical record.

question

Consultation report

answer

A narrative report of an opinion about a patient's condition

question

Diagnosis

answer

The scientific method of determining and identifying a patient's condition

question

Diagnostic procedure

answer

A procedure performed to assist in the diagnosis, management, or treatment of a patient's condition

question

Discharge summary report

answer

A brief summary of the significant events of a patient's hospitilization

question

Electronic medical record

answer

A medical record that is stored on the computer

question

Familial

answer

Occurring or affecting members of a family more frequently than would be expected by chance

question

Health history report

answer

A collection of subjective data about a patient

question

Informed consent

answer

The consent given by a patient for a medical procedure after being informed of the procedure

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Inpatient

answer

A patient who has been admitted to the hospital for at least an overnight stay

question

Medical impressions

answer

Conclusions drawn by the physician from and interpretation of data

question

Medical record

answer

A written record of the important information regarding a patient

question

Objective data

answer

A symptom that can be observed by an examiner

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Patient

answer

An individual receiving medical care

question

Physical examination report

answer

A report of the objective findings from the physician's assessment of each body system

question

Problem

answer

Any condition that requires further observation, diagnosis, management, or patient identification

question

Prognosis

answer

The probable course and outcome of a disease and the prospects for recovery

question

Subjective symptom

answer

A symptom felt by the patient but not observed by an examiner

question

Symptom

answer

Any change in the body or its functioning that indicates the presence of disease

question

List three functions of the medical record?

answer

1. Document the results of treatment and patients progress 2. Basis for decisions regarding patients care and treatment 3. Efficient and effective method by which info can be communicated between authorized personnel

question

What is the meaning of the acronym 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 health care clearinghouses, that use, store, maintain, or transmit health information

question

What is a Notice of Privacy Practices?

answer

A written document that explains to the patients how their protected health information will be used and protected by the medical office

question

List examples of when HIPAA does not require written consent for the use or disclosure of a patient's health information in the following categories: Treatment Payment Health care operations

answer

Treatment - Patient referral to a specialist, emergency care provided at the hospital, tests in a patient performed by a lab Payment - Determination of eligibility for insurance benefits, review of services provided for medical necessity, utilization review activities Health care operations - Quality assessment activities, contacting patients with information about care or treatment, employee review activities, training of healthcare students

question

What two general categories of information are included on a patient registration record?

answer

Demographic information and billing information

question

List three uses of the health history?

answer

1. Determine patient general state of health 2. Arrive at a diagnosis and prescribe treatment 3. Document any change in a patients illness after treatment has been initiated

question

What is the purpose of the physical examination?

answer

To provide objective data about the patient, which assists the physician in determining the patients state of health

question

What is the purpose of progress notes?

answer

Serve to document the patients health status from one visit to the next

question

List three categories of medication that may be included in a medication record.

answer

1. Prescription medication 2. OTC medication 3. Medication administered

question

What is the purpose of home health care?

answer

Minimize the effect of disease or disability by promoting, maintaining, and restoring the patient health

question

List 5 examples of home health services.

answer

Cardiac home care IV therapy Respiratory therapy Pain management Diabetes management Rehabilitation Maternal-child care

question

What is the purpose of a laboratory report?

answer

Relay the results of laboratory test to the physician to assist in diagnosis and treating disease

question

List 5 examples of diagnostic procedure reports.

answer

Electrocardiogram report Holter monitor report Siginoidoscopy report Colonoscopy report Spirometry report Radiology report

question

What is the purpose of a therapeutic service report?

answer

Designed to restore a patients ability to function

question

What is the difference between physical therapy and occupational therapy?

answer

Physical therapy helps a patient to regain function while occupational therapy helps a patient to adapt to new functionality

question

List examples of physical agents used in physical therapy.

answer

Thermal modalities, cold, hydrotherapy, electrical stimulation, and massage

question

What is speech therapy?

answer

Treatment for the correction of a speech impediment resulting from birth, disease, injury, or previous medical treatment

question

What is the purpose of an operative report?

answer

Describes the surgical procedure and must be completed and signed by the surgeon

question

What is the purpose of the discharge summary report?

answer

Document information needed by the patients physician to provide for the continuity of future care

question

What is included in a pathology report?

answer

Maroscopic and microscopic descriptions of tissue

question

Why is a copy of the emergency room report sent to the patient's family physician?

answer

For purposes of follow-up care

question

When is a consent to treatment form required?

answer

For all surgical operations and non-routine therapeutic and diagnostic procedures

question

What is the purpose of a consent to treatment form?

answer

Written evidence that the patient agrees to the procedures listed on the form

question

What information must the patient receive before signing a consent to treatment form?

answer

Nature of patients condition, nature and purpose of recommended procedure, explanation of risks involved with procedure, alternative treatment or procedures, likely outcome of procedure, risks of declining or delaying procedure

question

What does witnessing a signature mean? And what does it not mean?

answer

Means only that the medical assistant verified the patients identity and watched the patient sign the form. Does not mean the medical assistant is attesting to the accuracy of the info provided.

question

When must a patient complete a release of information form?

answer

For purposes not related to TPO

question

When does a release of medical information form not have to be completed?

answer

For the use or disclosure of PHI for the purpose of medical treatment, payment, and healthcare operations

question

What is the difference between a PPR and an EMR?

answer

One is a paper record while the other is compuerized

question

What functions are preformed by an EMR software program?

answer

Creation, storage, organization, editing, and retrieval of medical records on a computer

question

What are the advantages of the electronic medical record?

answer

Speed and productivity efficiency accessibility

question

How are paper documents entered into a patient's electronic medical record?

answer

Scanned

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