What is time format most healthcare institutions use
100
Medical Records can be hand-written, but what do facilities use the most?
What is Electronic Medical Record System
100
Subjective data
Objective data
Assessment
Plan
What is the Acronym for Soap?
100
This section of the patient's record documents any order of patient care.
What is physicians orders.
100
3 things a health provider should check for to assure accuracy in medical documentation
What is facts,correct spelling, errors
200
This allows health care workers to view, search, edit, and share patient information remotely
What is electronic documentation
200
Assessment data includes such information as?
What is Vital Signs, Circumstances surrounding the visit, symptoms experienced, and medical history.
200
The subjective part of the record includes any statement from the patient describing his or her condition and the objective part of the record includes information from the health care professional observations of the patient.
What is the difference between objective and subjective data?
200
This type of sheet contains a history of the patient's vital signs, along with the date they were taken.
What is graphic/graphic sheet.
200
patients have a moral and legal right to expect that the information contained in their patients record will be kept private. it is also guideline for documentation
What is confidentiality
300
Not sharing computer password/computer signature is an example of
What is safe computer keeping
300
______ is a great deal can be learned from reading a patients medical record.
What is an educational tool used by providers
300
Narrative notes
What is the kind of notes that are time-consuming to write and can be difficult to read?
300
The 5 vital signs that comply with a graphic sheet.
What is respiration rate, blood pressure, pulse, temp, and weight.
300
two ways patient records are usually organized
What is problem-oriented medical record and source-oriented medical record
400
Ease of access to data is an
What is an advantage of computerized documentation
400
There are two key purposes of Documentation. What are They?
What is COMMUNICATING with other health care professionals and DESCRIBING a patients medical Condition & History.
400
Define Progress notes
What is the name of the section that is used to summarize all relevant activities and is used by healthcare professionals from many different disciplines?
400
This form of notes records each contact a provider has with the patient, whether in person or by phone, email, or mail.
What is progress notes.
400
recognizes that the patient record is permanent. following the health care institutions policy
What is accountability
500
Advances in computer technology, medical recordkeeping software, and file transfer security are
What is reasons for conversion to computerized documentation
500
Health Care professionals are required to adhere to certain _____, ________, and ______ standards when managing medical documentation.
What is Legal, Moral, and Ethical
500
-Decreased charting time, which frees more time for direct patient care
-Greater emphasis on significant data
-Timely bedside charting
-easy retrieval of significant data
-lower costs
What is the benefits of charting by exception?
500
Two types of info that are contained in a medical record.
What is family history, patients history, social history, results of physical examination, or a current medical condition.
500
groups information by type instead instead by problem