Review for Exam 3

Views:
 
Category: Entertainment
     
 

Presentation Description

Med Office Admin Ch 8-12

Comments

Presentation Transcript

Medical Office Administration:

Medical Office Administration Review for Exam 3 Chapters 8 – 12

What does p.o. mean?:

What does p.o. mean? By mouth

What’s an “outguide?”:

What’s an “ outguide ?” It’s a control system for keeping track of a chart It serves as a place holder in the file cabinet when the chart is removed and others will know who took the chart

What are some advantages of EMR?:

What are some advantages of EMR? Faster More secure Centralized access Less chance for error (legibility, etc.) Easier to gather reports, generate billing, document outcomes Thanks to EMR, “Mouse calls” may be the wave of the future

What does t.i.d. mean?:

What does t.i.d . mean? Three times per day

How many unique identifiers should be on every page in the chart?:

How many unique identifiers should be on every page in the chart? TWO ~ usually patient’s name and date of birth

How would you file “Harold B. Smith, Jr.?”:

How would you file “Harold B. Smith, Jr.?” Smith Harold B. (Jr.)

How long are medical records usually kept?:

How long are medical records usually kept? Indefinitely

Electronic confidentiality guidelines include::

Electronic confidentiality guidelines include: Secure tapes and disks Log out when you leave computer Don’t allow passwords to be viewed and change them often Don’t download public domain software Don’t use outside disks Back up regularly Don’t explore others’ computers

What is ‘indirect’ filing?:

What is ‘indirect’ filing? It’s filing a patient’s chart by number instead of name Generally used for facilities with over 10,000 patients DISADVANTAGE is that personnel must cross-reference patient’s name with a number on master patient index to find the chart

How would you file ‘Blake lee-jones’?:

How would you file ‘Blake lee-jones’? Leejones Blake

What is another name for a short-notice reminder file?:

What is another name for a short-notice reminder file? A cancellation list

What does i. and ii. mean?:

What does i. and ii. mean? They mean ‘one’ and ‘two’ respectively

Which is more common today – paper medical record or electronic?:

Which is more common today – paper medical record or electronic? Paper!

What’s a charge-out system?:

What’s a charge-out system? It’s a control system for keeping track of a chart It requires that people “sign out” charts if they remove them from the filing area ~ it’s similar to checking out books from the library

Which record would appear first, second and third in the filing cabinet?:

Which record would appear first, second and third in the filing cabinet? Karen A. Jones, K. Jones-Smith, Dr. Karen Jones Jones, Karen (Dr.) Jones, Karen A. Jonessmith , K.

What are the purposes of the medical record?:

What are the purposes of the medical record? Aids in diagnosis and treatment of the patient Provides documentation of care Verifies medical necessity Assists in research (statistics) Substantiates billing codes Complies with laws Defends physician

“1 h.s.” is which part of the prescription?:

“1 h.s .” is which part of the prescription ? It’s the signature – directions for the patient

In regard to written communication, what does ‘pica’ mean?:

In regard to written communication, what does ‘pica’ mean? Pica is a type size on a typewriter 10 characters per inch Larger type than Elite

What does p.r.n. mean?:

What does p.r.n . mean? As necessary or as needed

There are five schedules of controlled substances. Which ones might an MA handle the prescpription?:

There are five schedules of controlled substances. Which ones might an MA handle the prescpription ? Only schedules IV and V IV permits other health care personnel (varies by State) to call in the prescription ordered by the physician or write up the prescription as long as the physician signs it. V sometimes doesn’t even require a prescription, but if it is prescribed, it can be phoned in

When does a physician need a DEA number?:

When does a physician need a DEA number? If he administers, prescribes, or dispenses any of the drugs listed as a Controlled Substance

What is the CC?:

What is the CC? Part of the medical history It means “Chief Complaint” or the primary reason for the patient’s visit It’s often a direct quote, “I think I have the flu.”

SOAP is::

SOAP is: Subjective Objective Assessment Plan

Which part of a SOAP note would include “Take two aspirin and call me in the morning.” ?:

Which part of a SOAP note would include “Take two aspirin and call me in the morning.” ? P for Plan

What’s is a “Pro” for problem-oriented charting?:

What’s is a “Pro” for problem-oriented charting? Each problem has its own flow sheet so it’s easy to track

Which part of a SOAP note would include, “Strep Throat” ?:

Which part of a SOAP note would include, “Strep Throat” ? A for assessment

What’s an HPI?:

What’s an HPI? History of present illness It’s the part of the medical history that expands upon the Chief Complaint to get more details from the patient

Oops – you made a mistake! The entry below should say “Lipitor” – how would you correct it?:

Oops – you made a mistake! The entry below should say “Lipitor” – how would you correct it? Lisinopril 20 mg, 1 p.o. q d Lipitor (Corr.) 3/16/11 SB Lisinopril 20 mg, 1 p.o. q d

What is an Outfolder?:

What is an Outfolder ? It’s a control system for keeping track of charts It’s a placeholder in the file cabinet for when a chart is removed; it tells the searcher who has the file AND it has a folder to store papers for future filing when the chart returns

Which chart would come first, second, third in the filing?:

Which chart would come first, second, third in the filing? Katy St.Laurent , Katy M. Saint Laurent, Katherine St.Laurent SaintLaurent , Katy M. StLaurent , Katherine StLaurent , Katy

Which schedule of the controlled substances act includes marijuana?:

Which schedule of the controlled substances act includes marijuana? Schedule I Which – by the way – has the “highest potential for abuse”

What does 1 gt q 5 h mean?:

What does 1 gt q 5 h mean? One drop every five hours

Which schedule of the controlled substances includes drugs that may not require a prescription?:

Which schedule of the controlled substances includes drugs that may not require a prescription? Schedule V Which has a limited potential for abuse and includes things like cough medicine with codeine

Which part of the SOAP note would include “Throat is red with white patches on the tonsils.”:

Which part of the SOAP note would include “Throat is red with white patches on the tonsils.” O ~ Objective This portion includes measureable, observable signs as reported by the clinician

The Social History includes things like::

The Social History includes things like: Hobbies, habits, smoking and alcohol history, marital status, sexual history, occupation, educational level

Which part of the medical history might reveal inheritable problems?:

Which part of the medical history might reveal inheritable problems? Family History

Which part of a SOAP note would include “Patient reports nausea and vomiting times three days and believes she has a fever.”:

Which part of a SOAP note would include “Patient reports nausea and vomiting times three days and believes she has a fever.” S ~ Subjective Subjective information is that reported by the patient, not necessarily measureable or observable

What does mcg mean?:

What does mcg mean? It means microgram (very small amount - one millionth of a gram) NOT the same as milligram (one thousandth of a gram which is 1000 times MORE than a microgram )

What is the advantage of Source-Oriented charting?:

What is the advantage of Source-Oriented charting? It’s very easy to find what you’re looking for because the chart is organized into sections and each section is in chronological order So what’s the “CON” to this method? It would be difficult to isolate a single problem because those records would be filed in various sections at various dates throughout the chart

Of problem-oriented and Source-Oriented charting, which one is more common?:

Of problem-oriented and Source-Oriented charting, which one is more common? Source-oriented is more common

What does “Authentication of documents” mean?:

What does “Authentication of documents” mean? Authentication means it requires a signature To authenticate a document, the signature of physician can be manual or electronic (faxed or a digital coded signature)

A physician listening to the lungs with a stethoscope is using which of the four procedures to examine a patient?:

A physician listening to the lungs with a stethoscope is using which of the four procedures to examine a patient? Inspection, Palpation, Percussion, Auscultation? Auscultation, which is ‘listening’

What is a prognosis?:

What is a prognosis? An expected outcome

What’s a “sign?”:

What’s a “sign?” O bservable, measureable objective information about a patient’s condition Examples include temperature, skin color, observed limping, blood pressure, pulse, respiratory rate and sounds, clammy cool skin, description of wounds or rashes, lab results, EKG’s, X-rays, grimace on the face, PERRLA, EOMI…

Who may prescribe schedule I drugs?:

Who may prescribe schedule I drugs? According to your text, no one Since Schedule I drugs have no known medical use, it can only be obtained by researchers with an official DEA form CLEARLY things have changed since this book was published because marijuana is being prescribed in some States

buccal:

buccal It means cheek Medication administration would be between the cheek and the gum

Which part of the SOAP note would include, “Rule out mono, possible Ebstein-Barr virus.”:

Which part of the SOAP note would include, “Rule out mono, possible Ebstein -Barr virus.” A ~ Assessment Assessment can include firm diagnosis but it can also include possible causes which still need further investigation. The “Plan” in this case would likely include testing for Mono and EBV and then doctor would re-visit his Assessment.

How does one “Instill” a medicine?:

How does one “Instill” a medicine? Instillation is by liquid drops We can instill medicine into eyes, ears…

What does the Inscription on a prescription include?:

What does the Inscription on a prescription include? The name and the dosage/quantity of ingredients of the medication For example, “ Carvedilol 12.5 mg”

What does “h.s.” mean?:

What does “ h.s .” mean? “hour of sleep” or at bedtime

What does OBRA require of pharmacies?:

What does OBRA require of pharmacies? They must do prospective drug utilization review to ensure there are no multi-drug contraindications They must offer patient counseling about meds They must maintain patient records They must hold a drug use review board

Parenteral means:

Parenteral means By needle or cannula through the skin Medications administered this way are parenteral

Three Drug Names include::

Three Drug Names include: Chemical name Brand name Generic name

What does mean?:

What does mean? With

The “Sig” or signature of a prescription includes::

The “Sig” or signature of a prescription includes: Directions for the patient Sig: 1 tab b.i.d . = Take o ne tablet twice a day

What does b.i.d. mean?:

What does b.i.d . mean? Two times per day

What is “Elite”?:

What is “Elite”? It’s a type size on a typewriter 12 characters per inch; it’s smaller than Pica

How does one administer a “topical” medicine?:

How does one administer a “topical” medicine? Topical medicines are placed on the skin

So you need to instill three drops of an otic solution…WHERE will you put these drops?:

So you need to instill three drops of an otic solution…WHERE will you put these drops? Otic means “ear” so will put drops in the ear

What does mean?:

What does mean? Without

What’s the difference between registered and certified mail?:

What’s the difference between registered and certified mail? Registered mail is first class mail with a declared value. Forms are filled out to confirm mailing and delivery dates. Certified mail is done when proof of mailing and delivery are needed; receipt is kept on file at the post office. BOTH may need “delivery confirmation” which can be purchased for an additional fee. The return receipt, signed by the recipient, is returned to the mailer for documentation purposes.

The subscription part of the prescription includes::

The subscription part of the prescription includes: Information for the pharmacist including total quantity and form of medicine For example, “#60 tablets”

How is a transdermal medicine administered?:

How is a transdermal medicine administered? Transdermal means “through the skin” It is generally medicine applied to a patch which, when stuck to the skin, allows the medicine to permeate the skin over time

What is “restricted delivery” of mail and when would it be advised?:

What is “restricted delivery” of mail and when would it be advised? Restricted delivery requires a specific person to sign for it Reasons?

The doctor tells your patient to take his nitroglycerin sublingually for chest pain…how is this medicine delivered?:

The doctor tells your patient to take his nitroglycerin sublingually for chest pain…how is this medicine delivered? Sublingual means “Under the tongue” so the patient will place the Nitroglycerin tablet under his tongue and just let is dissolve

How much information do patients forget after they leave the medical office?:

How much information do patients forget after they leave the medical office? 50 to 75% is forgotten How can you help them remember?

How is ophthalmic medicine delivered?:

How is ophthalmic medicine delivered? Into the eye

What part of the prescription is this?:

What part of the prescription is this? #90 capsules It’s the subscription

What part of the prescription is this::

What part of the prescription is this: Rx It’s the superscription – usually preprinted on the prescription pad and it means “recipe”

Email guidelines include::

Email guidelines include: Develop an office email policy about when to send/receive emails and when emails are an acceptable means of communication Use encryption and passwords Patient signs consent if email will be used Avoid identification in body or subject lines Print emails for documentation Identify staff with permission to check doctor’s email Answer emails within 24 hours Create auto-reply if you are out of the office

What causes multiple medication errors?:

What causes multiple medication errors? Poor interpersonal communication!

How can your medical office prevent drug abuses?:

How can your medical office prevent drug abuses? Watch for “drug seeking” behaviors Protect prescription pads Document inventories and when samples are given Keep drugs locked up

What’s a tickler file?:

What’s a tickler file? A reminder file

Can you name the parts?:

Can you name the parts? 1. Letterhead 2. Date line 3. Inside address 4. Attention line 5. Salutation 6. Reference or Subject line 7. Body 8. Complimentary closing 9. Signature line 10. Title 11. ID initials 12. Enclosure or attachment notation 13. Copy notation 14. Postscript

How Many patient identifiers should be on each page in the chart?:

How Many patient identifiers should be on each page in the chart? TWO!

authorStream Live Help