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MAC 101 Chapters 11 and 12 Flashcards | StudBud
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MAC 101 Chapters 11 and 12
MAC 101 Chapters 11 and 12
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1
Recording information into a patient’s medical record is called
documentation
description
transcription
dictation
2
This is found on the patient registration form
emergency contact
Social and Occupational history
lab results
patient allergies
3
All information should be entered in the record at the time of pt visit, not days, weeks, or months later. Done in..
development
due course
transcription
sequencing
4
What report would you generate to see who is not paying their bill
accounts recivable
aging
patient statistics
office statistics
5
When should you record exam and test results
as soon as they are available
every other friday
every friday afternoon
once a month
6
Which section of the CHEDDAR format of documentation can the diagnosis be found
History
Assesment
Examination
Cheif Complaint
7
The best way to make sure the licensed practitioner sees an x-ray result is to
have the practitioner initial the report
tell pt to give them the report
place the report in the inbox
have the nurse do it
8
What type of record is owned by the patient?
EHR
PHR
EMR
PHI
9
What is a disadvantage of an electronic scheduler
if the computer is down the daily schedule is not accessible
you can keep a list of patients who want earlier appointment
you must look at each page to find a patients forgotten appointment
multiple users may use it at any time
10
How do you make a correction in an electronic chart?
adding an addendum
striking through the error and adding initials
printing the page, correcting the error, and scanning the page
deleting the error
11
The role an MA plays in patient education is to explain
test results
the outcome of disease
the management of the patient's condition as outlined by the provider
what treatment is appropriate
12
The purpose of having a patient sign an informed consent form is to ensure
the provider does not have to document every visit
the provider may terminate care at any time
the patient has legal recourse against the provider
the patient understands the treatment offered and the possible outcomes
13
In legal terms, medical records regarded as this may damage a provider's position in a lawsuit
prompt
development
convenient
due course
14
The P section of SOAP documentation is
the diagnosis or impression
data provided by the patient
data provided by the provider
the plan of action
15
What is one of the most important duties of a medical assistant
fill out and maintain accurate and thorough patient records
tell the physician what is wrong with patient
point out to the patient how test results have changed
explain how the patients general health has improved or lessened
16
Medical errors due to communication are the ____ leading cause of death in the US.
5th
15th
20th
8th
17
At what age are you considered an adult in most states
21
17
16
18
18
What is the most appropriate way to terminate an initial interview with patient?
Is there anything else you would like the doctor to know?
I need to terminate the interview.
The lab tech will be in to draw blood.
The doctor will be in shortly.
19
An example of a patient sign is
nausea
a rash
pain
a headache
20
What year were all offices supposed to have EHR implemented
2009
2007
2012
2014
21
Subjective or internal conditions felt by the patient are
responses
outcomes
symptoms
signs
22
Doctor called pt to give lab results and there was no answer. It is your job as the MA to
remind dr to call patient at a later time
record date and time of call in chart
leave dr a message to call pt
attempt to call and relay dr information to pt
23
You would find the patient's illness and reason for a visit in the
in test results
records from previous provider
patient medical history
plan of action
24
How many identifiers are neededto correctly identify a patient's EHR?
1
at least 3
none
at least 2
25
Internal audits are done
by medical staff on random records
by the federal government
by agencies from outside the medical practice
to catch medical errors
26
Why should you not send a patient chart by fax machine
copies from fax are unclear
takes to long to fax each page
fax machine is unreliable
there is no way to tell who is seeing the chart
27
Data that comes from examination results and from the provider are charted in which section of the SOAP
Assessment
Plan
Subjective
Objective
28
What color ink is used to ensure handwritten records are the original versus a copy
blue
red
pink
black
29
In the CHEDDAR format, the C section includes
a list of current medications
presenting problems
consults
contributing info
30
Something that patient charts can be used for
evaluating patient satisfaction
showing results to other patients
patient care management
providing patient education
31
A summary of the reason a patient entered the hospital, care received and outcome of the hospitalization
hospital discharge summary
patient registration form
provider examination form
patient medical history
32
What could happen if an EHR coding software detects a code that has been deleted or does not match the diagnosis code
bill the patient erroneously
refuse to pay
produce a flag to alert the medical office
cause the computer to crash
33
When is it appropriate to send original documents?
when the record is subpoenaed for a court case
when patient signs an authorization to release them
when the record is going to another physician
never
34
Information such as laboratory test results, that are put into the EHR, are available for viewing when?
within 1 week
immediately
within 10 buisness days
within 2 days
35
What is the abbreviation for symptom?
sx
SP
sym
sympt
36
Which is a true statment about a personal health record
PHR information can be diclosed without patient consent
PHR may be stored and maintained on secure internet sites
PHR files contain treatment information
PT files are leagal documents and regulated by federal law
37
This organization reviews pt health records to monitor whether the care provided and fee charged meet accepted standards
The Joint Commission
American Hospital Association
American Medical Association
American Medical Society
38
Which is the most appropriate action in order to make a correction when an error has been made in the paper chart?
erase the error and correct it
cover with White-Out, write over it, and initial and date it
scribble out the error and write above it
draw a single line through the error, add correction/why, initial & date
39
Objective or external factors that can be seen or felt by the practitioner or measured by an instrument are called what
signs
behavior
feelings
outcomes
40
Important information on a patient's medical history and present condition are found in the
patient's health record
medical office book
medical transcription
POMR
41
An example of a symptom is
rash
pain
fever
high blood pressure
42
What does the A in SOAP stand for
assesment
action
adjusted
application
43
Documenting a patient walks down a hall as "fine" violates which of the 6 C's of charting
completeness
conciseness
clarity
confidentiality
44
PT got out of bed and walked 20 feet without reporting SOB. What is this an example of
too much detail
breech of confidentiality
lack of completeness
clarity
45
What is a patient portal?
a secure online website that gives patients access to PHI
a website to support breast cancer awareness
a link that takes you to a random health website
a portal that teleports physicians
