Abbreviations
to do immediately
What is ASAP?
owns the medical record
Who is the provider?
Director of a lab
What is a pathologist?
To detect medications or drugs that are excreted by the kidneys
What is urinalysis?
Draw a line through
What is when correcting an error?
VS
What is vital signs?
Importance of accurate medical records
What is one of the following:
The best possible medical care for the patient
Critical information for others
Legal protection for those who provided care to the patient
Statistical information that is helpful to researchers
Support for claims reimbursement
Director of a POL
What is a physician?
Includes assessing color, odor, clarity, and specific gravity
What is the physical characteristics of urine?
Alphabetic by name; Numeric; Subject
What is how to file charts>
UTI
What is urinary tract infection?
Patients must explicitly authorize the release of records
What is Notice of Privacy Practices (NPP)?
A numeric value is not attached to the test results
What is a Qualative Test?
sweet or fruity-smelling urine can indicate
What is diabetes?
Proper patient preparation
What is the MA's responsibility?
HTN
What is hypertension?
Subjective Information
What is
Personal demographics
Past health, family, and social history
Chief complaint: Concise account of the patient’s symptoms, which are explained in the patient’s own words.
Use methodologies that are simple/accurate; Pose no unreasonable risk of harm to the patient
What are CLIA-waived tests?
high specific gravity can indicate
What is dehydration or diabetes?
department is to identify the microorganism that is causing the infection
What is microbiology?
HBV
What is hepatitis B Virus?
Patient information is organized in sections for various purposes
What is SOMR?
The stage when the specimen is collected, labeled, and processed.
What is the preanalytic stage?
The test to test for blood in the stool
What is Hemoccult tests?
method of dcoumenting
What is SOAP notees?