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35 Cards in this Set
- Front
- Back
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What is the purpose of a medical record? |
-Patient assessment -Intervention -Communication |
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Does a medical record serve as a legal document? |
Yes |
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What is SOAP chart? |
Subjective Objective Assessment Plan -Notes are documented in the medical record in chronological order. ex. Dates - most recent goes on top. |
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What is a SOMR chart? |
Source-Oriented Assessment Record -Grouped by type of service |
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What is a POMR chart? |
Problem-Oriented Assessment Record -Grouped by services |
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Explain SOAP. |
Subjective - what the patient tells us Objective - what can be seen or heard Assessment - physician's findings Plan - treatment |
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What must be done before you can produce a claim form? |
The patient must sign a release form. |
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If an office is using color-coded filing systems, should everyone in the office know how to use the system? |
Yes |
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What must be placed whenever a chart is removed? |
An outguide |
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When filing in the alphabetic system, names are broken down into units. What are those units? |
Unit 1 - last name Unit 2 - first name Unit 3 - middle initial Unit 4 - professional title |
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If a patient said, "I feel like someone is stabbing me," is the statement a subjective statement or an objective statement? |
Subjective. |
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What would go under plan according to SOAP charting? |
Diagnostic tests, medication and treatments. |
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What would go under assessment according to SOAP charting? |
Doctor's preliminary diagnosis. |
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Who owns a medical record? |
The doctor owns the physical record, while the patient owns the information inside the record. |
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What type of filing system is used more often in physician offices? |
Alphabetic filing. |
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What is a tickler file? |
A reminder file; should be checked frequently. |
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How would you file businesses? |
You file under the subject, not the preposition. ex. The House of Wax - would be filed under H. |
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What is a closed question? |
A question with an answer of only yes or no. |
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Will a good communicator be effective in sending and receiving messages? |
Yes. |
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What is non-verbal communication? |
Body language. |
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What does verbal communication have? |
-Tone -Speed of speech -Content -Sighing |
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What are some things that will enhance the effectiveness of communication? |
-Willingness to understand (being open-minded) -Ability to understand the message -Understanding any cultural differences. |
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How would you spell the word meaning to advise? Council or Counsel? |
Counsel. |
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How would you spell the word meaning unable to move? |
Stationary. |
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When writing a business letter, what should you not do? |
You should not write down every word in the conversation for documentation. |
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What can you do to improve communication? |
-Use simple, everyday language with patients -Use passive and active listening skills -Identify any language barriers -Lower your level of education with patients, if needed. |
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What should you do when you've received a complaint from a patient? |
You should report the complaint to the office manager first. Never interrupt the physician for the complaint AT ALL. |
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What should you do when you have an elderly patient? |
Keep any counseling to a minimum with an elderly patient. |
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What should you do when you have a developmentally delayed patient? |
You should treat the patient on the level of maturation. |
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What should you do when you have a sight-impaired patient? |
Asked them: -Do you need help? -Can I help you? -How can I help you? |
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Define maturation. |
Growth and development process involving a person's physical, social, and emotional functioning. (Maturity) |
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Define disability. |
Patients who have impaired vision, impaired hearing, diminished mental capacity, and other physical disabilities. |
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Define rapport. |
Harmonious relationship that considers both physical and the emotional needs of those involved. |
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Define holistic. |
Involving all health needs of the patient, including physical, emotional, social, economic, and spiritual needs. ex. holistic patient care. |
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Define litigation. |
A lawsuit. |
