Charting
SOAP
Forms
Reports
True or False
100
How are documents filed in reverse chronological order?
What is: Placed in front of other documents
100
Symptom observed by another person
What is: Objective
100
DOB, Employer and pt's insurance; are found in what part of the pt's chart?
What is: Patient registration record
100
Report of an opinion of patient's condition by a practitioner other than the attending physician
What is: Consultation
100
The health history of a patient can provide subjective data to assist physician in arriving at a diagnosis.
What is: True
200
process of making written entries about a patient in the medical record
What is: Charting
200
Physicians interpretation of the patient's condition.
What is: Assessment
200
Demographic and billing information is found in
What is: Patient registration record
200
Analysis of body specimens
What is: Laboratory report
200
The Plan of treatment is included in the database section of a POR.
What is: False
300
What should be on a medication record for medications administered?
What is: Name of medication, route, dosage, refills
300
Data obtained from the patient are recorded in POR progess notes under:
What is: Subjective data
300
Provides patients with more control over the use and disclosure of their health information.
What is: HIPPA
300
Report that accounts of significant events of a patient's hospitalization.
What is: Discharge summary
300
The purpose of the tab on a file folder is to prevent the folder from being misfiled.
What is: False. Identify the contents of the folder.
400
When is health history taken on a patient?
What is: Before the physician performs the physical examination
400
Conclusions drawn from an interpretation of data
What is:Medical impressions
400
If patient transfers records to a new physician, pt must sign a:
What is: Release of medical information form
400
Macroscopic and microscopic descriptions of tissue
What is: Pathology report
400
The function of the medical record is to share information between members of the patient' family.
What is: False
500
What is past medical history?
What is: Patient's previous diseases, injuries and operations
500
Symptom causing the patient the most trouble.
What is: CC
500
What must be included in a informed consent form?
What is: explanation of risks, alternative tx, Prognosis, purpose of procedure.
500
Radiology report is filed under:
What is: Lab/xray
500
Occupational therapy helps a patient with a disability learn new skills to perform the activities of daily living
What is: True
M
e
n
u