1
what are the formats records can be stored?
electronic
paper
Social security number is objective or subjective information?
subjective
give me 3 examples of what the CC should include?
The nature, location, frequency and duration of pain if any.
When the patient first noticed symptoms
Treatments the patient may have tried before seeing the provider
Whether the patient has had the same or similar condition in the past
Other medical treatment received for the same condition in the past
Who owns the health record?
The owner of the physical record is the provider
or the medical facility often called the “maker”
Records of patients who have died, moved away or terminated their relationship with the provider
closed
Patients who the provider has not seen in 6 months or longer
inactive
How long should you store health records for?
10 years
information is grouped by the source
Source oriented records
Observations and data are
cataloged according to their
source
Source oriented
structured around the patient’s specific problems, often
using the SOAP format.
Problem oriented
give me 3 ways to make correction on health records
Draw one line through the error
Insert the correction above or immediately after the error
Write “error” in the margin (per office policy)
Initial and date
give me 3 examples of filing methods
Alphabetic
Numeric
Subject
Color Coding
nonverbal communication includes
Body language
Gestures
Mannerisms
Appearance
Self-esteem and confidence
Facial expressions
Casual person space includes how many inches ?
(18 inches to 4 feet)
What is the Communication Cycle?
Sender creates the MESSAGE
Receiver DECODES the message
Receiver creates FEEDBACK
Sender DECODES feedback
Most important therapeutic communication
technique
Active listening
asks for general information; encourages
patients to respond in a manner that they find
comfortable
open statements
name 3 communication barriers
Environmental distractions
Internal distractions
Visual impairment
Hearing impairment
Intellectual disability
Illiteracy
Inability to speak English
Emotional distractions
Understand Erikson’s stages of psychosocial
development
Industry vs. inferiority is what age range?
(6 to 12 years of age)
Kübler-Ross’s Stages of Grief
Denial
Anger
Bargaining
Depression
Acceptance
give me 3 examples of Maslow’s Hierarchy of Needs
Physiological needs
Safety needs
Love and belongingness needs
Esteem needs
Cognitive needs
Aesthetic needs
Self-actualization needs
Transcendence needs
All healthcare providers must provide free effective
communication to patients/companions with
disabilities
What is the term?
Americans with Disabilities Act (ADA)
examples of patient coaching include ?
Adapt to special needs
Write down information for a patient with a hearing
impairment
Use play techniques with kids
Exercising, eating healthy, talking with others is an example of which coping mechanism ?
Adaptive
Hostility, aggression, denial, drugs is examples of which coping method?
Maladaptive