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Ch 19 Ms Ferguson 100 Flashcards | StudBud
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Ch 19 Ms Ferguson 100
Ch 19 Ms Ferguson 100
27 terms
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Questions
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Answers
1
The ____ are the primary tool used to record, communicate and coordinate the care given to the patient
Dr orders
progress notes
flow sheets
Dr scripts
2
Properly dispose of docs that contain confidential pt info
biohazard bag
facility dumpster
regular office waste basket
burn
3
If pt states they only slept from 2am to 530am you record what in the notes
Patient needs help sleeping.
Patient states, “I only slept 3 ½ hours last night.”
Patient is sleeping poorly.
Patient reports difficulty sleeping.
4
Familial history includes the medical problems of relatives that may show a family tendency for problems.
False
True
5
Cybersecurity is the most serious concern with EHR
False
True
6
Collection of documents that forms the complete health history of a patient
medical documentation
medical record
charting
assessment
7
What is the purpose of medical documentation
prevents malpractice lawsuits
Helps ensure compliance with regulatory agencies
keeps cost low
prevents cyber attacks
8
HIPAA is federal government legislation and all health care providers must follow its rules.
True
False
9
The chief complaint is the primary reason the patient is seeking medical care.
False
True
10
HIPAA means/does what
it is a software app that only doctors use
protects the privacy of a pt
it is ok to give out pt information
control health costs
11
define charting
Provides legal protection
Recording observations and information about patients
collection of documents all filed together
complete chronological health history of a pt
12
Chronological record of care administered
Progress notes
diagnostic tests
graphics
Medical history
13
Which of the following personnel may write progress notes that are included in the patient’s official medical record?
all health care professionals who provide a direct service to the patient
only Drs.
only nurses
only Drs. and nurses
14
The federal govt. provided funds to health care providers who accept Medicare & Medicaid pts to set up EMR systems
False
True
15
When documenting in a chart what a pt says you
Write the statement in your own words.
Write direct quotes and enclose the entry in quotation marks.
Note the statement in a shortened form, using standard abbreviations.
List the symptoms, using correct medical terminology.
16
Subjective, objective, assessment, and plan (SOAP) notes are organized by health problems.
True
False
17
Past surgeries would be included where in the chart
personal history
family history
social history
social history
18
Reason the patient seeks medical care
Medical record
Chief complaint
Charting
Assessment
19
Source-oriented charting is organized by specialty.
False
True
20
A coworker asks you to sign a chart note that they forgot to you should
sign their name
sign both of your names
sign your name
refuse to sign either name
21
Medical record software is developed by various manufacturers, and many systems cannot communicate with each other.
False
True
22
to increase efficiency gather all the records for pts to be seen that day and prepare written documentation in advance
False
True
23
Electronic patient record systems can be very expensive.
True
False
24
PHR are documents created and maintained by the individual.
False
True
25
Only abbreviations approved by the facility should be used in charting.
True
False
26
Medical documentation refers to notes and documents that health care workers add to the medical record
True
False
27
Flow sheets are forms for specialty needs such as monitoring blood sugar levels or measurements of a wound as it heals.
False
True
