Lab 1 – Ch.1 The Medical Record

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The medical record serves as a legal document.
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True
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The purpose of progress notes is to update the medical record with new information.
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True
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The patient registration record consists of a list of the problems associated with the patient’s illness.
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False – Patient registration record consists of demographic and billing information.
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All OTC medications taken by the patient should be charted on the medication record form.
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True
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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
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A report of the analysis of body specimens is known as a diagnostic report.
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False – A Laboratory report
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Medical impressions are conclusions drawn from an interpretation of data.
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True
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A consent to treatment form is required for tuberculin skin testing.
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False – Consent to treatment forms are required for all surgical operations and non routine therapeutic and diagnostic procedures.
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Diabetes mellitus is an example of a familial disease.
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True
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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.
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True
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The health history provides subjective data about a patient to assist the physician in arriving at a diagnosis.
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True
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Physical therapy helps a patient with a disability learn new skills to perform the activities of daily living.
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False – this refers to occupational therapy physical therapy helps to promote healing after and illness or injury.
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A copy of the patient’s emergency room report is sent to the patient’s family physician.
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True
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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.
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False – witnessing a signature means only that the medical assistant verified the patient’s identity and watched the patient sign the form
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SOAP is the acronym for the format used to organize POR progress notes.
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True
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The chief complaint is the symptom causing the patient the most trouble.
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True
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The social history includes information on the patient’s lifestyle, such as health habits and living environment.
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True
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The patient’s name must be included at the beginning of each entry charted in the patient’s medical record.
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False
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A decrease in the amount of water in the body is known as edema.
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False – Edema is the retention of fluids in the tissue, resulting in swelling.
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Attending Physician
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The physician responsible for the care of a hospitalized patient.
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Chartting
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The process of documenting information about a patient in the medical record.
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Consultation report
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A narrative report of an opinion about a patient’s condition
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Diagnosis
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The scientific method of determining and identifying a patient’s condition
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Diagnostic procedure
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A procedure performed to assist in the diagnosis, management, or treatment of a patient’s condition
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Discharge summary report
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A brief summary of the significant events of a patient’s hospitilization
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Electronic medical record
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A medical record that is stored on the computer
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Familial
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Occurring or affecting members of a family more frequently than would be expected by chance
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Health history report
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A collection of subjective data about a patient
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Informed consent
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The consent given by a patient for a medical procedure after being informed of the procedure
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Inpatient
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A patient who has been admitted to the hospital for at least an overnight stay
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Medical impressions
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Conclusions drawn by the physician from and interpretation of data
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Medical record
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A written record of the important information regarding a patient
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Objective data
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A symptom that can be observed by an examiner
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Patient
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An individual receiving medical care
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Physical examination report
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A report of the objective findings from the physician’s assessment of each body system
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Problem
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Any condition that requires further observation, diagnosis, management, or patient identification
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Prognosis
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The probable course and outcome of a disease and the prospects for recovery
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Subjective symptom
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A symptom felt by the patient but not observed by an examiner
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Symptom
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Any change in the body or its functioning that indicates the presence of disease
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List three functions of the medical record?
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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
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What is the meaning of the acronym 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 health 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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A written document that explains to the patients how their protected health information will be used and protected by the medical office
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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
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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
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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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List three uses of the health history?
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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
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What is the purpose of the physical examination?
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To provide objective data about the patient, which assists the physician in determining the patients state of health
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What is the purpose of progress notes?
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Serve to document the patients health status from one visit to the next
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List three categories of medication that may be included in a medication record.
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1. Prescription medication 2. OTC medication 3. Medication administered
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What is the purpose of home health care?
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Minimize the effect of disease or disability by promoting, maintaining, and restoring the patient health
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List 5 examples of home health services.
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Cardiac home care IV 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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Relay the results of laboratory test to the physician to assist in diagnosis and treating disease
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List 5 examples of diagnostic procedure reports.
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Electrocardiogram report Holter monitor report Siginoidoscopy report Colonoscopy report Spirometry report Radiology report
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What is the purpose of a therapeutic service report?
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Designed to restore a patients ability to function
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What is the difference between physical therapy and occupational therapy?
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Physical therapy helps a patient to regain function while occupational therapy helps a patient to adapt to new functionality
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List examples of physical agents used in physical therapy.
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Thermal modalities, cold, hydrotherapy, electrical stimulation, and massage
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What is speech therapy?
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Treatment for the correction of a speech impediment 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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Describes the surgical procedure and must be completed and signed by the surgeon
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What is the purpose of the discharge summary report?
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Document information needed by the patients physician to provide for the continuity of future care
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What is included in a pathology report?
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Maroscopic and microscopic descriptions of tissue
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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 purposes of follow-up care
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When is a consent to treatment form required?
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For all surgical operations and non-routine therapeutic and diagnostic procedures
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What is the purpose of a consent to treatment form?
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Written evidence that the patient agrees to the procedures 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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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
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What does witnessing a signature mean? And what does it not mean?
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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.
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When must a patient complete a release of information form?
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For purposes not related to TPO
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When does a release of medical information form not have to be completed?
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For the use or disclosure of PHI for the purpose of medical treatment, payment, and healthcare operations
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What is the difference between a PPR and an EMR?
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One is a paper record while the other is compuerized
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What functions are preformed by an EMR software program?
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Creation, storage, organization, editing, and retrieval of medical records on a computer
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What are the advantages of the electronic medical record?
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Speed and productivity efficiency accessibility
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How are paper documents entered into a patient’s electronic medical record?
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Scanned
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What procedures typically are performed by a medical assistant using an EMR?
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