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63 Cards in this Set
- Front
- Back
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5 places computer used
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1 scheduling
2 communications 3 billing 4 clinical work 5creating/maint. pat.files |
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type of scheduling most used in medical offices
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electronic scheduling system
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4 advantages of electronic scheduling
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easy rescheduling
-print list of daily appts.-searching -reminder notices -keep track of dr time |
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what does a medical record contain?
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medical history, dr notes, medical reports, x-rays, charts & correspondce
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greatest advantage*** lol
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info can be accessed anywhere
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1 disadvantage to electronic records
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security
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5 types of communications (over the computer)
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word processing, e-mail, computer networks, internet, wireless communication
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what is used to :
enter, print, edit & format documents? |
word processing
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what does Voice-Recognition software do?
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changes words into text
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what is:
telecommunication system; exchanging written messages thru computer network |
email
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links computers together so hardware, software & data files can be shared
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networking
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database
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collection of related data
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patient data;
transaction data |
patient= info on patient
transaction=info on each visit |
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most powerful computer
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super computer
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computer used in large busineses
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mainframes
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less power than mainframes; resemble filing cabinet
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minicomputer
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4 categories of computer hardware
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1. processor
2.memory 3.input/out put device 4.storage devices |
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CPU (central processing unit) aka brains of computer
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processor
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allows processing of data
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RAM (random-access memory)
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function
input= output= |
input= receive data
output=send processed data back to user |
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ex/ input &output devices
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input- scanner, mouse
output-monitor, printer |
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proper conduct of phone calls is
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telephone etiguette
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screening calls
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evaluating calls & decide action
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4 situations take message
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rx refill, labs, attorney,unsatisfactoty progress, wants to talk 2 dr.
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4 types of call go thru to dr.
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emergency,patient calls acute illness, calls from other dr.s
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double booking
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2 patients booked @same time
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wave system
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open office hour ex/ 9am-10am come in
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open shelf files
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bookcase type shelves
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rotary circular files
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small desktop file; patient name on index card
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lateral files
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draws or shelves open horizontally
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mobile-aisle files
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open shelf files that move by motor
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outguide
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tells a folder has been moved from a file
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releasing
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initial or mark
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indexing
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mental process of selecting name
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tickler file
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file used to follow up actions
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accession book
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book that tells what #s are available for patient to use
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dead storage
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area for inactive patients
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open punctuation
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dnt use any punctuation outside the body of the letter unless the line ends with an abbreviation
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determine clarity
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editing
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endnotes
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end of report notes
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annotate
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write helpful notes
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priority mail
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2 days > 70 lbs
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express mail
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next day > 70 lbs
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certified mail
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get receipt
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greatest security mail type
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insured mail
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proofreading
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correcting errors
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chart notes
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record of outgoing patient care & progress
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history & physical
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complete medical history
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referral & consultation letters
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copies of letters sent to other dr.s
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correspondence
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all letters, faxes & notes of phone convos
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clinical forms
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immunization records
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medication list
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all rx taking
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4 reasons for maintaining medical record
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evidence of illness, legal record for practice, get reimbursement, as source of data for research
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chief complaint (cc)
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reason patient is there
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history of present illness (HPI)
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info on symptoms
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past medical history (PMH)
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list of illnesses patient has had thru out yrs
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social history
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marital status, smoking drinking
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review of systems (ROS)
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dr viiew of each body system
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objedtive
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dr findings
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assessment
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dr fndings
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plan
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treatment
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3 types of problem oriented medical record
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database, initial plan, problem list
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SOAP
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subjective, objective, assessment, plan
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