Ch 11 Flashcards


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1

The specific information required of a population that must be obtained when a new patient makes an appointment with the office is __________________

demographics

2

The best place to interview a patient is __________.

in a private room

3

The P section of SOAP documentation is __________.

the plan of action

4

The _________ summary form generally includes a summary of the reason the patient entered the hospital; tests, procedures, or operations performed in the hospital; medications administered in the hospital; and the disposition or outcome of the case.

discharge

5

Subjective or internal conditions felt by the patient are __________.

symptoms

6

When you document problems, be careful to distinguish between signs and symptoms. An example of a sign is __________.

rash

7

The primary problem for which a patient comes to see the healthcare provider is known as the_________ complaint.

chief

8

Part of creating timely and accurate records is maintaining a(n) _________ tone in your writing.

professional

9

A physical examination form that is used during an “oral examination” to identify any signs or symptoms the patient may be experiencing or reveal information about an illness or condition is called a review of _________ or ROS.

system

10

The appropriate way to delete information on a medical record is to __________.

draw a line through the original information so it is still legible

11

Everything that is entered into the patient’s health record by the medical assistant must be dated and ____________.

initialed

12

Medical records must be written neatly and legibly, contain up-to-date information, and present a(n) ___________ professional record of a patient’s case.

accurate

13

When you release medical information, always send _________ unless the record will be used in a court case, in which case you should send the original records.

copies

14

Internal audits are done

by medical staff on random records.

15

The O section of SOAP documentation is __________.

data that comes from examination results and from the physician

16

To reduce confusion in medical records, __________________ are being used less often, except for those that are very clear in meaning.

abbreviation

17

The informed _________ form verifies that a patient understands the treatment offered and the possible outcomes or side effects of treatment.

consent

18

In which section of the CHEDDAR format of documentation can the diagnosis be found?

assessment

19

In the problem-oriented medical record (POMR), which of the following includes a record of the patient's history, information from the initial interview, and any tests?

database