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39 Cards in this Set
- Front
- Back
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What is a records management system? |
The way patient records are created,filed,and maintained |
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Where are comparable files kept? |
On rolling shelves that slide along permanent tracks in the floor so that they can be stored close together when not in use to converse space |
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Where are records in a rotary circular filed stored? |
In a circular fashion,similar to revolving door,and are accessed by rotating the files |
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What is the most basic filing supply in the medical office? |
File folder |
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What can be skipped when returning patient documents to their medical record or returning the records themselves to their properly filled location? |
The coding step |
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To keep the document from being lost in the file or falling out,what can you use? |
Special paper containing self-adhensive Aras that allow smaller documents to be attached to a standard size sheet or,if it has writing on both sides,place it in a standard -size plastic sheet protector |
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Will you be able to duplicate the information within the file?if not what can you do? |
You might not be able to but you can try to reconstruct it by contacting insurance companies,laboratories,and other providers for copies of the original documents |
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The physician usually makes decisions of? |
How long to keep Inactive or closed files in the office before sending them to storage |
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How should a person's title such as Dr. or Major be treated? |
As the last filling unit |
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When is color coding used? |
When there is a need to distinguish files within a filing system |
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What information does the hospital discharge summary generally include? |
Information that summarizes the reason the patient entered the hospital;tests,procedures,and operations performed,medications administered,and the deposition or outcome of the case |
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What are signs? |
Objectives,or external factors that can be seen or felt by the physician or measured by an instrument |
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What are symptoms? |
Subjective,or internal,conditiond that are felt by the patient but are not necessarily apparent in a physical exa |
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What does the S section of SOAP documentation contain? |
Subjective data from the patient and includes the patient's description of his or her signs and symptoms,opinions and comments |
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The O ,or objective section of SOAP documentation contains? |
Data from the physician,examinations,and test results |
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Information corrected or added sometime after a patient's visit can be regarded as? |
Convenient and may damage the physician's position in a law suit |
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You must obtain a patient's signature on a () before releasing the patient's record? |
Written lease statement |
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When you release medical information . what should you do? |
Call the recipient to confirm that all materials were received |
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Who are the internal audits done by? |
The medical staff on randomly chosen records |
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What are padded envelopes used to send? |
Documents or materials,such as slides,that may be damaged in the normal course of mail handling |
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What does editing involve? |
Checking a document for factual accuracy,logical flow,conciseness,clarity,and tone |
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What must you do to create effective,proffesional correspondence that reflects well on the practice? |
Be sure that you use clear and concise language,the active voice,and an appropriate style |
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What does a dictionary tell you? |
How to spell,divide,and,and pronounce a word and what part of speech it is |
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Parcel post was formerly known as? |
Fourth -class mail |
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What is the physician's desk reference (pdr)? |
A dictionary of medications that is published yearly |
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What can priority mail be used for? |
First class items that weigh between 11ounces and 70 pounds |
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What is the signature block allowed with? |
The complimentary closing and is placed three to four lines below it,to allow space for the signature |
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Before you write a letter,what should you know and do? |
Know the type of person to whom you are writing,and decide if the tone should be formal or more relaxed |
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What 2 styles of punctuation are used in correspondence? |
Open and closed punctuation |
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The ( ) is one of the most commonly used formats in medical offices because it's quick and easy to write |
Full-block style |
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What can a letter head be? |
Cotton fiber bond or sulfite bond |
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What kind of voice should business letters be? |
Active voice unless you are conveying negative news |
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What should you do with items in a list? |
Single space items but leave an extra line between items |
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The signature block is aligned with? |
The complimentary closing |
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What do notations include |
Information such as the number of enclosures included with the letter and names of people who will be receiving copies of the letter |
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What are the 3 types of errors that can occur when you are preparing s document? |
Formatting,data,and mechanical errors |
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What are all electrical mail sent by? |
Medical office should sound professional because it represents your medical office to the recipient |
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( ) delivers packages and provide overnight letter and express services |
UPS,FedEx,DHL |
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What is the quickest USPS service,providing next -day and second -day delivery 365 days a year |
Express mail |
