Medical Office Procedures 9&13

documents the patients condition on admission to the hospital.

physical examination and findings; laboratory results

Provides a synopsis of the patients hospital treatment

precautions taken by office to protect records from natural or man-made disasters

treatment plan with instructions given to patient

SOMR; similar information is grouped together or info from similar sources are grouped together

summary of the information disseminated and discussions that occurred during the meeting

1st sheet in pts med record, basic demographics, pts insurance, employer, AKA face sheet

Type of organization where physicians can come and go, but structure remains intact

Which of the following doesn’t belong?

which item would not be considered confidential information in a healthcare setting?

patients account of illness, chief complaint

Does a physician have to sign documents before they are placed in a patients chart?

blood, urine, biologic specimens

the physician owns the paper; the patient owns the content

Identify which number would be filed first when a terminal digit filing system is used

An office supply cabinet should contain how many months’ worth of supplies?

Easily understood, gives written record of information communicated, cost effective

used to keep track of each number as it is assigned to a patient

Which of the following circumstances could medical information be released without an ROI?

employers must provide employees with PPE necessary to do their job

Provide details of trip schedule

How long does a facility have to retain patients medical records?

room size, number of attendees, refreshments, and equipment needed

records where a patient has not received treatment in a specific period of time

This identifies the location of a chart that has been removed from its location

patient or guardian if the patient is a minor

should be completed if an employee is injured or contaminated

Which of the following should be prepared before a meeting?

Which item would not be found in a medical record?

Which organization reviews the work practices of a health care organization for accreditation?

verifies that all essential information is in the chart

ergonomic programs for injury prevention help reduce injuries in the workplace

Identify which name would be filed first when an alphabetical filing system is used.

progress note; subjective, objective, assessment, plan

system that combines letters and numbers to arrive at a unique identifier for each patient

office cannot copy and release records received from another office

injury or disorder of the muscles, nerves, tendons, ligaments, and joints

file that reminds assistant of specific tasks, available in many computer calendar packages

method of filing

musculoskeletal disorders(MSD) make up 1/3 of all work-related injuries.

Identify which number would be filed first when a consecutive number filing system is used

assigning a color to a letter or number

informs participants of the subject of the mtg, serves as a plan for who is conducting the mtg.

draw a line through the error, initial/date it, enter correct info above it, use black ink

operates independently of its employees and stockholders

xray, MRI, CT, nuclear medicine, include name of film or procedure and radiologists findings

physicians determination of a patients illness or reason for office visit

national organization that reviews practices of health care facilities

released medical info that shouldn't be released; subject to termination and/or legal penalties

similar to SOAP, history of present illness, ROS, examination, impression, plan

detailed account of surgical procedure, preoperative and postoperative diagnosis

employers need to be aware of OSHA standards in the workplace

physician assumes all liabilities for the practice and makes all business decisions,

fitting the workplace to the worker, helps reduce injuries in the workplace

encounters with patient, phone calls, outside appts, other info related to pts medical care

employees have a right to know about workplace hazards

employees have a right to know about workplace hazards

primary reason a patient visits the physician

on a regular basis, usually yearly

maintaining med records; prepping med reports; releasing med info; compiling statistics; coding