Term
|
Definition
| an engagement; a meeting at a particular time |
|
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Term
|
Definition
| any surrounding influence |
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Term
|
Definition
| a small pamphlet or booklet of information |
|
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Term
|
Definition
| the act of communicating; information given; a means of giving information |
|
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Term
|
Definition
| to be held in confidence; secret information |
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Term
|
Definition
|
|
Term
|
Definition
| taking action to modify, hinder, or change an effect |
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Term
|
Definition
| one employed to greet telephone callers, visitors, patients, or clients |
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|
Term
|
Definition
| to arrange a timetable; to place in a list of things to be done |
|
|
Term
| when preparing a checklist for opening the office |
|
Definition
unlock the reception room door
adjust heat/air conditioning
check for safety hazardous
check magazines
check phone for messages
pull charts
check examination rooms
fill and turn on sterilizer
prepare hazardous waste disposal containers
prepare list of patients |
|
|
Term
| what is the role of the receptionist |
|
Definition
| to greet and receive patients |
|
|
Term
| why is the reception room atmosphere important |
|
Definition
| it affects the outcome of the office visit from patients' response to treatment |
|
|
Term
| name six things to check in the reception room |
|
Definition
temperature
general appearance
safety
reading material
toys and books
"no smoking" sign |
|
|
Term
| list information that might be included in a practice information brochure |
|
Definition
description of practice
office policies
appointment information
office hours
biographical sketch |
|
|
Term
| why should social climate be monitored |
|
Definition
| annoying behavior may cause infavorable impressions or effects |
|
|
Term
| list some desirable characteristics for a receptionist |
|
Definition
prompt
courteous
pleasant tone of voice
maintains eye contact
listens intently
shows caring
provides confidentiality
looks and acts professionally
well-groomed
uses tact |
|
|
Term
| prepare a checklist for closing the office for the day |
|
Definition
examination rooms should be restock and cleaned
Discharged material should be placed for pick up
collect charts and check completeness
file in locked cabinet
turn off electrical appliances and autoclave
deposit receipts or lock in safe
tidy reception area
pull next day's charts
activate answering system
turn off lights
activate the alarm system
lock door |
|
|
Term
| preparation procedures for the day are the same for every office |
|
Definition
F
(it vary from one office to anoher according to the type of practice, number of physicians, weekly schedules, and many other variables) |
|
|
Term
| Charts should be pulled before the first patient arrives |
|
Definition
|
|
Term
| Telephone messages can be retrieved at lunch time |
|
Definition
F
(at the start of the work day and at specific intervals throughout the day) |
|
|
Term
| The receptionist must have a basic understandings of common diseases and disorders and basic office operational procedures |
|
Definition
|
|
Term
| Insurance cards should be requested when the patients check in |
|
Definition
|
|
Term
| It is not necessary to check the common work areas for cleanliness |
|
Definition
F
(the common areas of work should be checked for cleanliness periodically throughout the work day) |
|
|
Term
| the charge slip is also known as the encounter form |
|
Definition
|
|
Term
| it is important fot the receptionist to be discreet when asking the patient for information at the front desk |
|
Definition
|
|
Term
a medical record consists of all of the following except:
a. patient information form
b. health history
c. diagnostic reports
d. treatment notes
e. personal comments |
|
Definition
|
|
Term
which area of the office will give the first impression to patients?
a. waiting area
b. exam room
c. reception area
d. rest rooms |
|
Definition
|
|
Term
| the receptionist should have a clear view of the |
|
Definition
| waiting area/reception room |
|
|
Term
which of the following forms must accompany the patient to the exam room?
a. new patient form
b. history form
c. charge slip
d. none of these answers |
|
Definition
|
|
Term
|
Definition
| to pile up; collect; gather |
|
|
Term
|
Definition
| heading, title, or subtitle |
|
|
Term
|
Definition
| the arrangement of events, dates, etc., in order of occurrence |
|
|
Term
|
Definition
| facts from which conclusions can be inferred |
|
|
Term
|
Definition
|
|
Term
|
Definition
| enlightening; throwing light on |
|
|
Term
|
Definition
| to empty; to cleanse of impurities; clear |
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|
Term
|
Definition
|
|
Term
|
Definition
|
|
Term
|
Definition
| something added; an additional or extra section |
|
|
Term
|
Definition
|
|
Term
|
Definition
| not productive; no accomplishment |
|
|
Term
|
Definition
| making a decision regarding the name, subject, or other caption under which you will file the material |
|
|
Term
| name and define the four basic filing methods |
|
Definition
alphabetic: arranged in order of alphabet
numeric: filed by number, but must have alphabetic index to locate numbers
subject: may be arranged by equipment and supplies, or disease and illness
geographic: arranged by state, city, and subdivisions |
|
|
Term
| name and define the five steps in filing |
|
Definition
inspect: look at each piece and make indication by check mark or initial in upper-right corner when material is released to be filed
index: make decision as to name, subject, or caption under which to file material
code: underline or circle caption to be filed under, or write caption on paper if necessary
sort: place material to be filed in order after coded; either alphabetically or numerically
store: place in storage drawer or shelf in proper place |
|
|
Term
| describe the proper method of placing material in a file folder. |
|
Definition
| place material with heading to the left so it is at the top of the folder when opened with the tab at right. The most recent material is on top in the folder |
|
|
Term
| describe the most efficient method of removing and replacing patient files |
|
Definition
| use OUTfolder to replace the removed folder. in replacement of folder, locate the OUT guide or OUTfolder and remove it as the original folder is inserted |
|
|
Term
| list the storage media used for "paperless" filing systems. |
|
Definition
| magnetic tape reels, cartridges, cassettes, magnetic disks, microforms |
|
|
Term
| describe ways to find a missing chart |
|
Definition
1) look through several charts in the file that are before and after where the missing chart should be
2)check the name of the chart you need and look in the section of the alphabet of the person's first name
3)check the charts pulled for the day
4)check the schedule of the day you know the patient was in last and check the charts of patients seen before and after
5) look in the charts-to-be-filed stack or cart
6) search the desks of other hearlth care team members in your facility |
|
|
Term
| bar code files eliminate the need for |
|
Definition
|
|
Term
| placing all documents in a patient's chart in _________ order makes it easier to obtain information |
|
Definition
|
|
Term
| the method of filing that provides the most patient privacy is |
|
Definition
|
|
Term
| in a miscellaneous file, when there are more than ________ paper on one subject or person, you should remove them and make a separate folder |
|
Definition
|
|
Term
| _________ make it easy to obtain phone numbers and addresses |
|
Definition
|
|
Term
| removing the files of patients who are no longer being seen by the physician is called |
|
Definition
|
|
Term
| when there is a signature on a patient's chart, J. Williams (CL), whose initials are in the parenthesis? |
|
Definition
|
|
Term
which of the following should be indexed first?
a. Alison B. Williams
b. Alease A. Wilkins
c. Allison B. Williams
d. Alice C. Willems
e. Ann A. Wiles |
|
Definition
|
|
Term
which of the following would be included as a purpose of records management?
a. reference
b. storage
c. classifying
d. arranging
e. all of these answers |
|
Definition
| arranging, reference, storage, and classifying |
|
|
Term
| which of the following is a chronological filing system that specifies a date when an action is needed? |
|
Definition
|
|
Term
which of the following should be indexed first?
a. Betty O. San Louis
b. James P. St. George
c. John R. St. Michael
d. William L. St. John
e. Judy del la Rosa |
|
Definition
|
|
Term
| which of the following is the most common way to file material charts? |
|
Definition
|
|
Term
which of the following is not a common record that needs to be managed in the medical office?
a. medical
b. financial
c. correspondence
d. business |
|
Definition
|
|
Term
which of the following is not a part of the filing process?
a. sorting
b. storing
c. rending
d. inspecting
e. releasing |
|
Definition
|
|
Term
|
Definition
|
|
Term
|
Definition
| the recording of observations, subjective and objectives findings, diagnostic procedures, treatments, and other pertinent data in the patient file. |
|
|
Term
|
Definition
|
|
Term
|
Definition
| the end toward which action is directed; of a disease symptom, perceptible to persons other than the one affected; on a microscope, a lens or series of lenses |
|
|
Term
|
Definition
| one who intentionally delys or postpones action |
|
|
Term
|
Definition
| record of the continuing progress and treatment of a patient |
|
|
Term
|
Definition
| relating to the person who is thinking, saying, or doing something; personal; of a disease sysmptom, felt by the individual but not perceptible to others |
|
|
Term
| Give examples of "subjective informaiton" |
|
Definition
| Information supplied by the patient: past personal and medical history; family history; chief complaint. |
|
|
Term
| Give examples of "obejectiveinformaiton" |
|
Definition
| Information supplied by the physician: examination by physician; result of lab studies; special procedures; X-rays; diagnosis; treatment prescribed; progress notes. |
|
|
Term
|
Definition
| A record of a patient's first visit and of continuing care; includes date, complaints, findings, prognosis, and treatment |
|
|
Term
| Describe methods of recording progress notes |
|
Definition
| medical assistant may record as physician examines patient; physician may record; physician may dictate and medical assistant transcribe |
|
|
Term
| describe the correct procedure for making corrections on progress notes |
|
Definition
| draw a single line through handwritten entry, date, and initial of maker of correction in margin; if typing, should be corrected in usual manner if corrected at time of typed; later corrections are handled as handwritten ones |
|
|
Term
| list of differences a traditional record and the Problem Oriented Medical Record (POMR) |
|
Definition
Traditional--Progress notes are recorded according to source, physician, lab technician, or medical assistant. There is no special attempt to record a relationship between recorded notes.
POMR--has a numbered and entitled page for each problem needing management. Each problem is followed with SOAP approach: S=subjective impressions, O=Objective clinical evidence, A=assessment or diagnosis, P=plans for further studies, treatment, or management. The chart is easier to review because of its organizaation |
|
|
Term
| why is procrastination a hindrance with patient's medical records |
|
Definition
| it can cause mistakes to be made, and some documents may never get done. Also, it may be needed in case of a suit |
|
|
Term
|
Definition
|
|
Term
|
Definition
|
|
Term
| what informaiton in a medical record makes it a useful legal document |
|
Definition
| progress notes, dates of treatments, and dates of injuries |
|
|
Term
| which of the symptoms listed below are objective? |
|
Definition
| rash, swelling, and bleeding |
|
|
Term
| which of the symptoms listed bellow are subjective? |
|
Definition
| nausea and abdominal pain |
|
|
Term
| besides the clinical visit findings, what additional information is recorded on progress notes? |
|
Definition
| phone messages, phone/fax refills, and cancellations |
|
|
Term
| what ink color should be used when recording patient information |
|
Definition
|
|
Term
| the confidentiality of the patient's medical record must be maintained by careful management |
|
Definition
|
|
Term
| only parts of the patient's record are necessary when the patient wishes the physician to testify in an injury case |
|
Definition
F
(the physician should have all parts of the patient's record so that the patient's complete history is known. |
|
|
Term
| The patient must always sign an authorization form before any information can be released |
|
Definition
|
|
Term
| all patient information contained in the medical record is considered subjective information |
|
Definition
F
(information contained in the patient record is both subjective and objective) |
|
|
Term
| progress notes should be arranged in chronological order with the most recent date on top |
|
Definition
|
|
Term
| the date and time should be recorded on the page for progress notes each time the patient is seen |
|
Definition
|
|
Term
| using correction fluid recommended to completely eliminate an error made on patient's records |
|
Definition
F
(The use of correction fluid is prohibited to correct an error in the patient record |
|
|
Term
| using black ink on the patient's record is important for making good copies |
|
Definition
|
|
Term
| the POMR begins with the standard database |
|
Definition
|
|
Term
| which of the following is considered to be the most important record kept in the medical office |
|
Definition
|
|
Term
the purpose of the patient medical record is that it:
a. furnishes documented evidence of the patient's evaluation and treatment
b. protects the legal interests of both the patient and the physician
c. establishes a database
d. is the basis for planning patient care
e. all of the above |
|
Definition
|
|
Term
which of the following statements about HIPAA is not true
a. HIPAA designates what information is released and to whom
b. HIPAA allows each clinic to do what it feels is reasonable with patient informaiton
c. HIPAA mandates that only certain employees are expected to comply with the regulations
d. HIPAA mandates the privacy and security of medical records |
|
Definition
| HIPAA mandates that only certain employees are expected to comply with the regulations |
|
|
Term
| how often should a patient's demographic information be updated |
|
Definition
|
|
Term
| referral or follow-up letters from specialists should be filed in which section of the medical record? |
|
Definition
|
|
Term
| a prescription refill should be documented in which part of the medical record? |
|
Definition
|
|
Term
| which of the following may be the cause of legal action against a physician? |
|
Definition
incorrect documentation in the patient's medical record
improper correction of an error in the patient's medical record |
|
|
Term
| all of the following are formats for documentation in the patient's medical record except... |
|
Definition
|
|
Term
| Calling a patient with lab test results is part of a process known as |
|
Definition
| following up test results |
|
|
Term
| what is the first step in finding a missing chart? |
|
Definition
| double check the location where the file should have been filed |
|
|
Term
| all interactions with patients and the physician or other medical office or clinic personnel must be documented in the patient's chart |
|
Definition
|
|
Term
| over the counter meds do not need to be recorded in the patient's chart |
|
Definition
|
|
Term
| a deceased patient's file should be removed from the filing system immediately on their death and transferred to a deceased patient storage area |
|
Definition
F
(it should be delayed until all requests for forms have been completed) |
|
|
Term
| The SOAP process of charting is more complicated then other methods of charting, makes the chart harder to review, and hinders thte follow-up of all problems the patient may have |
|
Definition
F
(it makes the chart easier to review and helps in the follow-up of all problems the patient may have) |
|
|
Term
| which of the following is the simplest and most common filing system? |
|
Definition
|
|
Term
| files are usually urged from an active filing status when they have been inactive for 5 or more years |
|
Definition
F
(Patient files are generally purged from an active status if the patient has not been seen in 2 years or more) |
|
|
Term
which of the following is one of the important purposes of a complete medical record?
a. tracking missed appointments
b. financial history
c. documentary evidence |
|
Definition
|
|
Term
| if a physician orders diagnostic testing for a patient that will not be performed in his or her office or clinic, it is imperative that the physician refer the patient to a participating provider of the patient's insurance company. Failure to do so will result in the physician being responsible for the cost of the diagnostic test. |
|
Definition
|
|
Term
| Lawrence Weed, MD, introduced the POMR method of medical record keeping in the 1970s. What does the abbreviation POMR stand for? |
|
Definition
| Problem-oriented medical record |
|
|
Term
which of the following is NOT considered objective information in a patient's chart?
a. X-rays
b. medical history
c. lab results |
|
Definition
|
|
Term
| if an error has been made in documenting information in a patient's chart, the error should be corrected using opaque correctin fluid and a red pen |
|
Definition
|
|
Term
which one of these examples is not considered part of a complete medical office or clinic record?
a. DNR order
b. patient information
c. treatment notes |
|
Definition
|
|
Term
| all office records should be kept in closed files when not in use |
|
Definition
|
|
Term
| the laws and regulations governing medical recordsvary from state to state, but usually medical records are kept for 3 to 7 years |
|
Definition
|
|
Term
| information in a medical record is classified as subjective or objective |
|
Definition
|
|
Term
| the introduction of HIPAA in 1996 caused many changes in how the medical office protects patient's medical information |
|
Definition
|
|
Term
| When filing documents in patient charts indexing the documents first speeds up the process |
|
Definition
F
(sorting the materials to be filed helps speed up the process of filing) |
|
|
Term
| Out-guides are used to temporarily replace folders that have been removed from a filing system |
|
Definition
|
|
Term
which one of the following is NOT a step used when filing?
a. storing
b. coding
c. copying |
|
Definition
|
|
Term
| insurance companies routinely send representatives to perform chart audits |
|
Definition
|
|
Term
| to prevent an injury from occurring when filing charts in a filing drawer, it is best to place files in the top drawer first |
|
Definition
F
(it is best to place files in the bottom drawer first to help avoid the possibility of injury) |
|
|
Term
| In demonstrating compliance with the HIPAA Security Ruling within a workplace, documentation is not one of the categories reviewed during an audit. |
|
Definition
F
(Documentation is one of the categories that is reviewed during a HIPAA Security Ruling audit) |
|
|
Term
| what should be included in a complete and detailed medical record? |
|
Definition
| patient information and diagnostic reports |
|
|
Term
| the correct body mechanics for holding an object would be to hold the item at arm's length with the elbows locked |
|
Definition
F
(hold the object close to the body) |
|
|
Term
| all documentation including chart notes in a patient's medical record is considered part of the permanent record |
|
Definition
|
|
Term
| what date did the HIPAA privacy standards for all medical data became effective? |
|
Definition
|
|
Term
| first names that are abbreviated should be indexed as if they were spelled out in full. |
|
Definition
|
|
Term
|
Definition
| The organization and storage of all kinds of records |
|
|
Term
|
Definition
Alphabetic filing:
1. Names of People
2. Names of Businesses and
Organizations
3. Government names
4. Addresses
Alphabetic correspondence filing:
Subject correspondence filing
Electronic filing
Geographic filing
Numeric filing |
|
|
Term
|
Definition
| The way the names in the white pages of a telephone directory are organized |
|
|
Term
|
Definition
| names that arranged according to area or location |
|
|
Term
|
Definition
|
|
Term
|
Definition
| the way personal checks are often arranged |
|
|
Term
|
Definition
| names are arranged like this in the yellow pages of the phone book |
|
|
Term
|
Definition
|
|
Term
|
Definition
| evidence or documentation of an organization's activities |
|
|
Term
|
Definition
|
|
Term
|
Definition
| arranging names in alphabetic order |
|
|
Term
|
Definition
| refers to whether it is capitalized or not/ in small or large letters |
|
|
Term
|
Definition
| the mental process of deciding which name or heading under which a record is to be filed as Unit 1, Unit 2, and so on |
|
|
Term
|
Definition
| the name or heading under which a record is filed |
|
|
Term
|
Definition
| a sheet of cardboard used to separate sections of a file |
|
|
Term
|
Definition
| a piece of cardboard, plastic, or metal attached to the top of a guide |
|
|
Term
|
Definition
| the part closest to you when you are working with the file |
|
|
Term
|
Definition
| the part of the file farthest from you when you are working with the file |
|
|
Term
| rule for arranging names in alphabetic order |
|
Definition
| nothing comes before something |
|
|
Term
|
Definition
| used when a record might be filed under more than one caption |
|
|
Term
|
Definition
| approved by giving initials |
|
|
Term
|
Definition
| checking to see that correspondence is released or approved for filing. |
|
|
Term
|
Definition
| inspecting, indexing, coding, sorting, and storing |
|
|
Term
|
Definition
| the process of identifying on a piece of correspondence the caption under which that correspondence will be filed |
|
|
Term
|
Definition
| arrange in alphabetic order according to the captions |
|
|
Term
|
Definition
|
|
Term
|
Definition
| piece of heavy cardboard that is used to separate the major alphabetic sections of a file |
|
|
Term
| each primary guide is placed |
|
Definition
| beginning of an alphabetic section |
|
|
Term
|
Definition
| last folder in a section( it follows all the individual folders) |
|
|
Term
|
Definition
| is a container for records about one correspondent or subject |
|
|
Term
| There are six of these folders, two behind each primary guide |
|
Definition
|
|
Term
| there are three of these folders |
|
Definition
| primary folder and miscellaneous folder |
|
|
Term
|
Definition
|
|
Term
|
Definition
| where business records are stored |
|
|
Term
|
Definition
|
|
Term
|
Definition
|
|
Term
|
Definition
| Personal Name with Prefixes |
|
|
Term
|
Definition
| Hyphenated Personal Names |
|
|
Term
|
Definition
| Abbreviations of Personal Names |
|
|
Term
|
Definition
| Personal Names with Titles and Suffixes |
|
|
Term
| When indexing the name of a person arrange the units in this order |
|
Definition
| last name, first name or initial, middle name or initial |
|
|
Term
|
Definition
| part of the name it precedes |
|
|
Term
| Ignore any apostrophe or space that appears within or after the prefix |
|
Definition
|
|
Term
| Consider a hyphenated first, middle, or last name as one unit |
|
Definition
|
|
Term
| Abbreviated and shortened forms of personal names are indexed are written |
|
Definition
|
|
Term
Titles & Suffixes
When used with a person's name, it is the last indexing unit when needed to distinguish between 2 or more identical names |
|
Definition
|
|
Term
|
Definition
|
|
Term
Title & Suffixes
Index as written |
|
Definition
|
|
Term
| the 5 ways to arrange records in files |
|
Definition
Alphabetically
By Subject
Chronologically
Numerically
Geographically |
|
|
Term
|
Definition
| evidence or documentation of an organization's activties |
|
|
Term
|
Definition
|
|
Term
|
Definition
| each part of the name of a person, organization, or company that is used to arrange the name in alphabetic order |
|
|
Term
|
Definition
| Berg, Chung, and Dodge are an example |
|
|
Term
|
Definition
| whether it is capitalized or not capitalized/ |
|
|
Term
|
Definition
| iit makes no difference whether a letter is uppercase or lowercase |
|
|
Term
|
Definition
| the mental process of deciding under which name, or heading, to file a record |
|
|
Term
|
Definition
| the name or heading under which a record is filed |
|
|
Term
|
Definition
| a sheet of cardboard used to separate section of a file |
|
|
Term
|
Definition
| a piece of cardboard, plastic, or mental attached to the top |
|
|
Term
|
Definition
| is not considered in indexing |
|
|
Term
|
Definition
| part of the file closest to you when you are working with the file |
|
|
Term
|
Definition
| part of the file farthest to you |
|
|
Term
| nothing comes before somthing |
|
Definition
| rule for arranging names in alphabetic order |
|
|
Term
|
Definition
|
|
Term
| what to do if two names are identical |
|
Definition
| use the address to determine the filing order |
|
|
Term
|
Definition
|
|
Term
Commonly used abbreviation
Charles |
|
Definition
|
|
Term
Commonly used abbreviation
Elizabeth |
|
Definition
|
|
Term
Commonly used abbreviation
George |
|
Definition
|
|
Term
Commonly used abbreviation
James |
|
Definition
|
|
Term
Commonly used abbreviation
Joseph |
|
Definition
|
|
Term
Commonly used abbreviation
Robert |
|
Definition
|
|
Term
Commonly used abbreviation
William |
|
Definition
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Term
Commonly used titles
Captain |
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Definition
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Term
Commonly used titles
Doctor |
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Definition
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Term
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Definition
| checking to see that correspondence is ready to be filed |
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