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Labeling paper charts
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Reports
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100

The purpose of a Medical Record

To keep track

100

Numeric seniority units are filled BLANK alphabetic 

Before 

Example:

•Edward Lee Smith II is filed BEFORE Edward Lee Smith Jr

•George Lee Curtis IV BEFORE George Lee Curtis Sr

100

Where is the HPI (History of present illness) located?

In the H&P (History and physical report)

100

What type of document is an x-ray report?

Radiology & Imaging report


100

If the patient expires during the hospital stay, the report will be labeled as a

death summary

200

Describes the gross & microscopic exams performed on organs, lesions, tissue samples, or body fluid removed during a surgical procedure

Pathology Report

200

How should Joellen M. de la Vara be indexed? 

Delavara, Joellen M.

200

What is the document's name that may include, sponge count & instrument inventory?

Operative Report 

200

If the patient is transferred to another facility, such as a skilled nursing facility, the report is labeled as a

transfer summary


200

State law requires an autopsy be performed in the following situations:

●Sudden, unexpected death,

●when someone dies unattended

●Crime or suspicion of crime

300
Name 4 things included in a discharge summary

●reason for admission

●description of what transpired while in the hospital

●final diagnosis

●follow up instructions

●discharge medications

●patient's condition at time of discharge

●prognosis for recovery

300

How should Prof. Marcia Tai Lewis be indexed? 

Lewis, Marcia Tai Prof

(Lewis is unit 1)

(Marcia is unit 2)

(Tai is unit 3)

(Prof is unit 4)

300

What is included in Demographics or “Facesheet"?

Includes patient name, address, phone number, email, health insurance info, marital status, emergency contacts, historical and future clinic appointments, etc.

Often, Health Insurance Cards and Identification Cards accompany this information in the chart.

300

Radiology reports are filed by date or BLANK rather than date of BLANK

service, dictation

300

What is the name of Joellen's black lab?

Major

400

How would you file patient charts with identical names?

Use/Reference other identifiers such as:

• DOB, SS #, Address, or phone #

400

How should Brenda C. Hughes-Callahan be indexed? 

Hughes-callahan, Brenda C.

400

A method that serves as a reminder that some future action is needed

Tickler Files

400

What is an autopsy report? 

documents findings of exam to determine cause of death, & to ascertain or confirm presence of disease. May also be called an autopsy protocol, necropsy report or medical examiner report.

400

Documents the patient's history of a hospital admission

Discharge Summary

500

Who owns the patient record?

The law states that medical records are the property of the one creating them

500

Using INDEX Rules to create and sustain accurate medical records is important: What are the index units?

  Unit 1- Patient’s last name 

  Unit 2-Patient’s first name

  Unit 3-Patient’s middle name or initial

500

For an autopsy: Temporary anatomic diagnosis should be placed in the medical report within BLANK hours, and the report should be completed within BLANK days

72, 60

500

What is a consultation report?

A report that is generated when one healthcare provider requests the services of another provider in the care & treatment of a patient.

500

What does SOAP stand for

S - Subjective impressions

O – Objective impressions

 A - Assessment or Diagnosis

 P - Plans for further studies, treatment, or management

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