practice management & EHR, chapter 6 – Flashcards
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history of present illness (HPI)
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a description of the course of the present illness, including how and when the problem began, up to the present time
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social history (SH)
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information about the patient's tobacco use, alcohol and drug use, sexual history, relationship status, and other significant social facts that may contribute to the care of the patient
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review of systems (ROS)
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an inventory of body systems in which the patient reports signs or symptoms he or she is currently having or has had in the past.
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past, families, and social history (PFSH)
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a commonly used abbreviation for past medical, family, and social history
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T/F Patients' vital sign measurements are entered in the Progress Notes folder in the patient chart
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F
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T/F Each history section of a patient's chart consists of multiple notes.
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F
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T/F Patient allergies are recorded and stored in the Rx/Medications folder of the patient chart
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T
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T/F A typical patient flow consists of check-in, patient intake, exam, and checkout.
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T
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T/F The first step in opening a patient chart is to select Open Chart on the file menu or to click the Chart button on the toolbar.
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T
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T/F The History dialog boxes are used to select a patient
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F
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T/F Using Medisoft Clinical Patient Records, staff members can send intra-office messages
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T
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T/F Medications that have been added, discontinued, or changed are noted in the patient chart
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T
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T/F The history of present illness (HPI) includes previous treatment and diagnostic tests.
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T
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T/F A patient's chief complaint is recorded in the Medical History folder of the patient chart.
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F
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The __________ is the patient's history of medical problems, including chronic conditions, surgeries, and hospitalizations.
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past medical history (PMH)
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The _________ is information about the patient's tobacco use, alcohol and drug use, sexual history, relationship status, and other significant social facts that may contribute to the care of the patient.
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social history (SH)
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The _________ details medical events among members of the patient's family, including the ages, living status, and diseases of siblings, children, parents, and grandparents.
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family history (FH)
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The ____________ documents the care delivered to a patient, and the medical facts and clinical thinking relevant to diagnosis and treatment.
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progress notes
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_________ are sent to patients, other providers, employers, insurance companies, and others.
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letters
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The ___________ tab is in the Rx/Medications dialog box.
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current, ineffective, historical
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In the most practices, the _____________ is entered as the title of the progress note for the patient's visit.
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chief complaint
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An ______________ is a mild reaction to a medication and doesn't involve an immune system response.
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intolerance
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Abnormally high blood pressure readings are highlighted in _________ in the Vital Signs dialog box.
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red
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To open a new message in the inbox, select the _______ button on the toolbar.
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Msg
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SH
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social history
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PMH
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past medical history
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FH
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family history
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HPI
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history of present illness
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ROS
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review of systems
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PFSH
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past, family, & social history
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