stud
bud
Sign up
Log in
Home
Library
Explore
SAT
More
MAC 101 ch 11 and 12 review Flashcards | StudBud
Explore
/
MAC 101 ch 11 and 12 review
MAC 101 ch 11 and 12 review
50 terms
·
StudBud Administration
·
125 plays
Imported from external platform
Flashcards
50 cards
F
Practice quiz
P
Host live
L
Questions
50
Answers
1
PT got out of bed and walked 20 feet without reporting SOB what is this an example of
too much detail
breech of confidentiality
clarity
lack of completness
2
In the CHEDDAR format, the C section includes
a list of current medications
presenting problems
contributing info
consults
3
what are some things that patient chart can be used for
evaluating patient satisfaction
patient care management
showing results to other patients
providing patient education
4
What is a patient portal?
A portal that teleports physcians
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
5
where is the pt history and present history found
Patient Health Record
medicaloffice book
POMR
medical transcription
6
Documenting a PT walk down a hall as "fine" violates which of the 6 C's
clarity
completeness
confidentiality
conciseness
7
best way to make sure Dr sees an xray result
have nurse
place report in the inbox of Dr
have them initial the report
tell pt to give Dr the report
8
what is the most appropriate way to terminate an initial interview with patient
is there anything else you would like the dr to know
the lab tech will be in to draw blood
dr will be in shortly
i need to terminate the interview
9
An example of a patient sign is
nausea
pain
a headache
a rash
10
what year was all offices supposed to have EHR implemented
2007
2009
2014
2012
11
what is one of the most important duties of a medical assistant
point out to the patient how test results have changed
explain how the patients general health has improved or lessened
fill out and maintain accurate and thorough patient records
tell the physician what is wrong with patient
12
Objective or external factors that can be seen or felt by the practitioner or measured by an instrument are called what
feelings
behavior
signs
outcomes
13
A report generator is used to…
all of the above
print files on paper
update files
to generate electricity
14
what are examples of patient symptom
rash
fever
high blood pressure
pain
15
What does the O stand for in SOAP?
Ogre
Object
Objective
Order
16
What type of record is owned by patient
PIR
PHR
MRI
EHR
17
What is the abbreviation for symptoms?
SP
Sx
Sym
Sympt
18
where would you find the reason for patient visit
patient medical history
in test results
icheif complaint
records from previous provider
19
What does the P stand for in the SOAP Notes system?
power
prepare
plan
paper
20
when should you record exam and test results
every friday afternoon
once a month
as soon as possible
every other friday
21
Informed consent means:
the person is fully capable of making decisions
the person has the power to decline the procedure
the person understands the risks and the benefits
all of the above
22
The role an MA plays in PT education is to explain
what treatment is appropriate
managment of the pt condition as outliend by provider
test results
the outcome of disease
23
Internal audits are done
to catch medical errors
by medical staff on random records
by agencies from outside the medical practice
by the federal government
24
why should you not leave a patient chart by the fax machine
fax machine is unreliable
there is no way to tell who is seeing the chart
copies from fax are unclear
takes to long to fax each page
25
how do you make a correction in electronic chart
printing the page, correcting the error,and scanning the page
deleting the error
adding an addendum
striking through the error and adding initials
26
what could happen if an EHR coding software detects a code that has been deleted or does not match diagnosis code
bill the patient enrroneously
cause the computer to crash
produce a flag to alert the medical office
refuse to pro
27
Dr calls a pt to give lab results and pt does not answer and ther is no voicemail to leave message what do you do
remind dr to call patient at a later time
record date and time of call in chart
attempt to call and relay dr information to pt
leave dr a message to call pt
28
Physician is going to work from home what is something that he will not be able to do from home with the EHR
update patient file
access patient records from home computer
diagnose software problems on his home computer
save patients record to the central office computer
29
you have a patient that has moved, got new insurance, new job what would you need to do as a MA?
all info does not fit make note on reg form to see updated patient reg form
get updated information
use correction tape to cover old information
shred old registration
30
at what age are you considered an adult
25
21
17
18
31
what is a true statment about Personal health record PHR
PHR may be stored and maintained on secure Internet sites
PT files are leagal documents and regulated by federal law
PHR information can be diclosed without patient consent
PHR files contain treatment information
32
What does the A in CHEDDAR stand for
Assesment
History
Cheif Complaint
Examination
33
what type of chart could be harmful to a physician in a lawsuit
due course
prompt
convenient
development
34
Subjective and Internal conditions felt by PT are what
signs
SOAP
Symptoms
POMR
35
what is not a reason for development and promotion of EMR
increasing age of the general population
Increase in medical errors
increasing need for coordination of care
rising healthcare cost
36
Process of recording information to patient’s medical record is called
Documentation
Demographics
Auditing
SOAP
37
when is it appropriate to send original documents in PHR
when patient signs an authorization to release them
when the record is going to another physician
when the record is subpoenaed for court case
never
38
what is not an advantage of intergrating labs and other diagnostic and theraputic services with an EHR
PT and physicians do not have to wait as long for results
test results are transmitted to Dr office as soon as they are available
PT does not have to wait as longf for lab or diagnostic appointments
results can be faxed , scanned, or emailed as neccessary
39
what information is on a patient information sheet
Social and Occupational history
emergency contact
lab results
patient allergies
40
how many identifiers are neededto correctly identify a PT EHR
none
at least 2
1
at least 3
41
All information should be entered in the record at the time of pt visit , not days ,weeks or months later this
sequencing
development
due process
transcription
42
Medical errors due to communication are the ---- leading cause of death in the US
15th
20th
5th
8th
43
what report would you run to see who is not paying there bill
aging
patient statistics
office statistics
accounts recivable
44
what is a disadvantage of electronic scheduler
you can keep a list of patients who want earlier appointment
you must look at each page to find a patients forgotten appointment
if the computer is down the daily schedule is not accesible
Multiple users may use it at any time
45
what organization reviews pt health records and monitors care provided and fees charged
american medical association
american medical society
american hospital association
the joint commision
46
Which is the most appropriate action in order to make a correction when an error has been made in the chart?
Cover with Wite-Out, write over it, and initial and date it
Draw single line through error. Write correct entry and put initials & date
Erase the error and correct it
Scribble out the error and write above it
47
information sush as result of laboratory test into EHR are available for veiwing when
within 1 week
immediately
within 10 buisness days
within 2 days
48
A discharge summary is
a set of educational materials provided at discharge
part of the patient's bill
a series of summary notes made by the providerof care
a summary of the patient's stay from admission to discharge
49
What color ink is prefered for handwritten documentation in a patient's medical record
Blue
Red
Black
Pink
50
what does the A in SOAP stand for
action
assesment
adjusted
application
