Need to know
Information that is gained by questioning the patient, or taken from a form
confidential
subjective
objective
necessary
Which of the following is not objective information
progress notes
family history
diagnosis
physical examination and findings
process of moving an active file to inactive status
purging
indexing
coding
conditioning
The type of electronic health record information about an individual created gathered managed in a Single healthcare organization
PHR
EHR
EMR
PHI
Active listening involves
listening to what the speaker is saying
interpreting the message
restating the message
all of the above
Which of the following is not needed when a patient describes a chief complaint
remedies the patient has tried for symptoms
the duration of pain
the time when the symptoms were first noted
how many famiy members are healthy
The medical record should be released on with a
verbal order from the DR.
written order from the Dr.
written release from the patient
verbal order from the office manager
The physical medical record belongs to
patient
physician or provider
insurance co.
all of the above
How are corrections made to electronic health record
A new entry or addendum must be added close to the original entry
incorrect entry is deleted and a new one is written in
the error is bought to the managers attention
The filing system that uses a combination of letters and numbers
terminal digit
numeric
alphanumeric
alphabetic
Index Jill Freemen, M.D. for filing
Dr. Jill Freeman
Freeman, Dr. Jill
Freeman, Jill
Freeman, Jill M.D.
Medical facilities should keep records on minors for
indefinately
until the minor is deceased
for 10 years
until the minor reaches age of majority
A correction to a medical record can be made by
drawing a line through the entry and writing correct
whiting out the entry
rewriting the entire page of progress notes
all of the above
An electronic record of health-related information that can be drawn from multiple sources, managed, shared, controlled by the individual
EHR
PHR
EMR
None of the above
Which type of call should be limited in the office
local
long distance
toll free
personal
Continuity of care
a collection of activities designed to ensure quality
formal examination of an individuals account
medical attention hat continues smoothly from 1 provider to another.
granted or endowed with a particular authority
Most frequently used follow up method
tickler file
transitory file
practice management file
none of the above
The advantages of using color-coding filing system
misfiled record is easily spotted
use of color visually restricts the area of search
you can use either alphabetic or numeric coding
all of the above
What is pitch
depth of sound
choice of words
quality of being clear
Calming an angry caller
speaking in a lower tone of voice
getting angry in return
passing the situation off
calling the physician
which statement is not true regarding the reasons for keeping accurate medical records
medical record provides critical info for caregivers
effects of various treatment can be tracked
The pts. family may want to examine the records
accurate records are vital for financial reimbursements
Files for pts. who have died, moved away, or otherwise terminated their relationship
inactive
closed
active
dead
Who ultimately decides whether a medical record can be released
the physician
office manager
MA
patient
What is professional jargon
Encephalagia
backache
earache
headache
Common calls in the office
other physicians
new patients
laboratories
all of the above