Patient Management & Interview
This step confirms the correct exam was ordered before the procedure begins.
What is verification of order?
This provides a chronological record of a patient’s interactions with healthcare providers.
What is a medical record?
This type of question encourages the patient to provide detailed information rather than a simple yes or no answer.
What is an open-ended question?
This is the patient’s main reason for seeking medical care.
What is the chief complaint?
This is one thing written records must be, meaning they should be correct and free from errors.
What is "accurate"?
The sonographer does this so the patient understands what will happen during the exam.
What is explanation of the procedure?
This type of record is used within one healthcare setting and is less portable.
What is an EMR?
Asking follow-up questions to gather more information about a patient’s symptoms is called this.
What is probing?
Determining where a symptom is occurring is known as this.
What is localization?
Written records should be written in this rather than full sentences.
What is "phrases"?
During this process, the sonographer gathers signs, symptoms, and exam-related information.
What is the patient interview?
This type of record is comprehensive and more portable between healthcare institutions.
What is an EHR?
During the data collection process, the sonographer should avoid asking these types of questions that suggest an answer.
What are leading questions?
This legal document contains a patient’s medical information and history.
What is a chart (or medical record)?
This type of purpose for record keeping helps protect healthcare workers and facilities in legal situations.
What are "Medico-legal purposes"?
This uses two identifiers according to department policy.
What is patient identification?
This law protects patient confidentiality in healthcare documentation.
What is HIPAA?
Repeating important information back to the patient helps ensure this.
What is accuracy (or understanding)?
One element of clinical history that refers to how severe a symptom is.
What is severity?
When correcting a charting mistake, you should do this to the incorrect entry instead of erasing it.
What is "draw a line through it"?
After correcting a charting error by drawing a line through it, these two things must be also added.
What are "your signature and date"?