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Chapter 1: The Medical Record Key Term Assessment1.Q11.S2.E12.H3.B13.K4.N14.L5.R15.T6.J16.O7.I17.C8.P18.M9.A19.D10.F20.GEvaluation of Learning1.List three functions of the medical record.The physician uses the information in the medical record as a basis for making decisions regarding the patient’s care and treatment; it serves to document the results of treatment and the patient’s progress and provides an efficient and effective method by which information can be communicated to authorized personnel in the medical office; it also serves as a legal document.2.What is the meaning of the acronym HIPAA?Health Insurance Portability and Accountability Act.3.What is the purpose of the HIPAA Privacy Rule?To provide patients with more control over the use and disclosure of their health information.4.Who must comply with HIPAA?All health care providers, health plans, and health care clearinghouses (e.g., billing services) that use, store, maintain, or transmit health information.5.What is a Notice of Privacy Practices?A written document provided to patients that explains how their protected health information will be used and protected by the medical office.6.List examples of when HIPAA does not require written consent for the use or disclosure of a patient’s health information in the following categories:a.Treatment: Patient referral to a specialist, emergency care at a hospital, and laboratory performing tests on a patient.b.Payment: Determination of eligibility for insurance benefits, reviewing services provided for medical necessity, and utilization review activities.c.Health care operations: Quality assessment activities, contacting patients with information about care or treatment, employee review activities, and training health care students.7.What two general categories of information are included on a patient registration record?Demographic and billing information.8.List three uses of the health history.To determine the patient’s general state of health, to arrive at a diagnosis and prescribe treatment, and to observe any change in a patient’s illness after treatment has been instituted.9.What is the purpose of the physical examination?To provide objective data about the patient that assists the physician in determining the patient’s state of health.10.What is the purpose of progress notes?To document the patient’s health status from one visit to the next.11.List three categories of medication that may be included in a medication record.Prescription medications, OTC medications, and medication administered at the medical office.12.What is the purpose of home health care?To minimize the effect of disease or disability by promoting, maintaining, and restoring the patient’s health.13.List five examples of home health services.Cardiac, infusion (IV) therapy, respiratory therapy, pain management, diabetes management, rehabilitation, and maternal-child care.14.What is the purpose of a laboratory report?To relay the results of laboratory tests to the physician to assist in diagnosis and treatment of disease.15.List five examples of diagnostic procedure reports.Electrocardiogram, Holter monitor, sigmoidoscopy, colonoscopy, spirometry, radiology, and diagnostic imaging.16.What is the purpose of a therapeutic service report?To document the assessments and treatments designed to restore the patient’s ability to function.17.What is the difference between physical therapy and occupational therapy?Physical therapy involves the use of physical agents to restore function and promote healing after an illness or injury; occupational therapy helps the patient learn new skills to adapt to a disabling condition.18.List examples of physical agents used in physical therapy.Therapeutic exercise, thermal modalities, cold, hydrotherapy, electrical stimulation, and massage.19.What is speech therapy?Treatment to correct a speech impairment resulting from birth, disease, injury, or prior medical treatment.20.What is the purpose of an operative report?To describe a surgical procedure performed on a patient.21.What is the purpose of the discharge summary report?To provide information to the patient’s (family) physician for the continuity of future care and to respond to authorized requests for information regarding a patient’s hospitalization.22.What is included in a pathology report?A macroscopic and microscopic description and diagnosis of tissue removed from a patient during surgery or a diagnostic procedure.23.Why is a copy of an emergency room report sent to the patient’s family physician?For the purpose of providing follow-up care.24.When is a consent to treatment form required?For all surgical operations and nonroutine diagnostic and therapeutic procedures performed in the medical office.25.What is the purpose of a consent to treatment form?To provide written evidence that the patient agrees to the procedure(s) listed on the form.26.What information must the patient receive before signing a consent to treatment form?The nature of the patient’s condition, the nature and purpose of the recommended procedure, an explanation of any risks involved with the procedure, any alternative treatments or procedures available, the likely outcome (prognosis), and risks involved with declining or delaying the procedure.27.What does witnessing a signature mean? What does it not mean?It means that the medical assistant verified the patient’s identity and watched the patient sign the form. It does not mean that the medical assistant is attesting to the accuracy of the information provided.28.When must a patient complete a release of medical information form?For purposes that are not part of medical treatment, payment, and health care operations (example: moving and having records forwarded to a new physician).29.When does a release of medical information form not have to be completed?For medical treatment, payment, and health care operations.30.What is the difference between a PPR and an EMR?A PPR is a paper-based patient record; an EMR is an electronic medical record.31.What functions are performed by an EMR software program?Creation, storage, organization, editing, and retrieval of a medical record on a computer.32.What are the advantages of the electronic medical record?EMRs can be retrieved quickly, do not need to be filed, reduced paper costs, time saved in not having to look for lost charts, easier to enter data into the record, ability to generate customized patient education instructions/handouts, to generate prescriptions, ready access to the patient record, and more than one person can view the chart at the same time.33.How are paper documents entered into a patient’s electronic medical record?By scanning them in.34.What procedures typically are performed by a medical assistant using an EMR?Access the daily schedule, select a patient, enter the time the patient checks in, enter the examination room number, enter the patient’s chief complaint, enter or review the patient’s history, enter or review patient allergies, enter or review the patient’s current medications, enter vital signs, enter height and weight measurements, enter results of tests, and enter laboratory test results.35.How are documents organized in a source-oriented medical record?They are organized into sections based on the department, facility, or other source that generated the information.36.What is reverse chronological order?The most recent document is placed on top or in front of the others.37.How are documents organized in a problem-oriented medical record (POR)?They are organized by the patient’s health problems.38.List and describe the four parts of a POR.Database: A collection of subjective and objective data used to compile a patient list.Problem list: A list of patient conditions that require observation, diagnosis, management, or patient education.Plan: A plan of action for further evaluation and treatment of each problem.Progress notes: The follow-up for each problem in SOAP format.39.List and describe the format used to organize progress notes in a POR.Subjective data: Data obtained from the patient.Objective data: Data obtained by observation, physical examination, laboratory, and diagnostic tests.Assessment: Physician’s interpretation of the current condition based on an analysis of the subjective and objective data.Plan: Proposed treatment for the patient.40.How can a health history be entered into the EMR?Patient completes a health history form and the MA scans it into the computer; the MA enters the information directly into the computer while asking the patient questions; the patient completes a computer-generated questionnaire.41.What are the seven parts of the health history?Identification data, chief complaint, present illness, past history, family history, social history, and review of systems.42.What is a chief complaint?The symptom that is causing the patient the most trouble.43.What guidelines should be followed in recording the chief complaint?An open-ended question should be used to elicit the chief complaint.The chief complaint should be limited to one or two symptoms and should refer to a specific rather than a vague symptom.The chief complaint should be recorded concisely and briefly.The duration of the symptoms should be included in the chief complaint.Names of diseases or diagnostic terms should be avoided in recording the chief complaint.44.What is the current illness, and how is this information obtained?A full and detailed description of the patient’s current illness from the time of its onset. It is obtained through a series of questions.45.List five examples of information included in the past medical history.Major illness, childhood diseases, unusual infections, accidents and injuries, hospitalizations and operations, previous medical tests, immunizations, allergies, and current medications.46.List three examples of familial diseases.Hypertension, heart disease, allergies, and diabetes mellitus.47.Explain the importance of the social history.The patient’s lifestyle may have an impact on the condition of that individual and influence the course of treatment chosen by the physician.48.What is the purpose of the review of systems (ROS)?To assist in identifying symptoms that might otherwise remain undetected.49.List the guidelines that should be followed to ensure accurate and concise charting.Check the name on the chart before making an entry.Use black ink to make entries.Write in legible handwriting.Chart information accurately, using clear and concise phrases.Chart immediately after performing a procedure.Each charting entry should be signed by the person making it.Never erase or obliterate an entry.50.List three examples of subjective symptoms.Pain, pruritus, vertigo, and nausea.51.List three examples of objective symptoms.Rash, coughing, and cyanosis.52.What is the difference between a productive and a nonproductive cough?With a productive cough, a discharge is produced. With a nonproductive cough, no discharge is present.53.Why should the following be charted in the patient’s medical record?a.Procedures performed on the patient To document that the procedure was performed.b.Specimens collected from the patient To let the physician know that the specimen was collected and sent to the laboratory when test results are not back yet.c.Laboratory tests ordered for the patient If the patient does not undergo the test, documented proof exists that the test was ordered.d.Instructions given to the patient regarding medical care To document instructions given to the patient in the event that he or she fails to follow the instructions and causes further harm or damage to a body part.Critical Thinking ActivitiesA. Medication Administration RecordRefer to the medication administration record (see Fig. 1-2) in your textbook, and answer the following questions.1.Does Kristen Antle have any allergies? No.2.How much Rocephin was administered to Kristen? 500 mg.3.What was the route of administration of the Rocephin injection, and where was it administered? Intramuscular in the right dorsogluteal.4.What is the name of the company that manufactures Rocephin? Roche.B. Consultation ReportRefer to the consultation report (see Fig. 1-3) in your textbook, and identify the following information using the corresponding letter (A, B, C, or D).1.Documentation that the consultant reviewed the patient’s health history2.Documentation that the consultant examined the patient3. A report of the consultants’ impressions4.A report of the consultants’ recommendationsRefer to Figure 1-3.C. Radiology ReportRefer to the radiology report (see Fig. 1-5) in your textbook, and answer the following questions.1.What type of radiological examination was performed on Rose Baker? PA of the chest and abdomen.2.Were the lungs clear? Yes.3.Were any abnormal masses noted in the abdomen? No.D. Diagnostic Imaging ReportRefer to the diagnostic imaging report (see Fig. 1-6) in your textbook, and answer the following questions.1.What type of diagnostic imaging procedure was performed on Vera Ruth? CT of the lumbar spine.2.What vertebrae of the spine were scanned? L3 through S1.3.What problem may affect L4-5? Annular disk bulge or protrusion on the left.4.What additional tests might be scheduled for Vera Ruth? Computed tomography of the lumbar spine.E. Discharge Summary ReportRefer to the discharge summary report (see Fig. 1-10) in your textbook, and answer the following questions.1.How long was Susan Brennan hospitalized? Three days from June 14 to June 16.2.What was her hemoglobin level at admission? 10.8.3.What was the reason for the hospitalization? Pelvic inflammatory disease; rule out ectopic pregnancy.4.Was Susan pregnant? No.5.What was her discharge diagnosis? Pelvic inflammatory disease.F. Release of Medical InformationRefer to the release of medical information form (see Fig. 1-14) in your textbook, and answer the following questions.1.What medical information is protected by law and cannot be released unless specifically authorized by the patient? Drug abuse diagnosis and treatment, alcoholism diagnosis and treatment, mental health diagnosis and treatment, and sexually transmitted disease.2.List reasons why a patient may authorize the release of his or her medical information. Taking records to another physician, moving, legal purposes, insurance purposes, and workers’ compensation.3.After this form is completed and signed, how long is it valid before it expires? 60 days.4.What must the patient do if he or she wants to revoke the authorization? Notify the medical office in writing.G. Chief ComplaintIndicate whether each of the following statements is an incorrect (I) or correct (C) example of recording a chief complaint (CC). If the example is incorrect, explain which recording guideline is not being followed.: Low back pain I: The duration of the symptom is not included.: Sore throat and fever for the past 2 days C.: Dyspnea, paleness, and fatigue similar to that associated with anemia, which has lasted for 2 weeks I: Names of diseases should not be used to record the chief complaint.: Poor health for the past several months I: Refers to a vague rather than a specific symptom.: Weakness and fatigue related to poor eating habits and lack of exercise I: Diagnostic terms should be avoided; the duration of the symptom is not included.: Heart palpitations occurring after drinking coffee in the morning before work I: The chief complaint should be recorded concisely and briefly; the duration of the symptom is not included.H. Crossword Puzzle: Directions: SymptomsComplete the crossword puzzle using the terms provided.AcrossDown?2 Stool is hard and dry?1 Fast pulse rate?4 Blue skin due to lack of O2?2 Shivering?5 Nosebleed?3 May be productive or nonproductive10 Skin eruption?5 Fluid retention11 Dizziness?6 Ejection of stomach contents14 No appetite?7 Decreased H2O levels in the body15 Yellow skin?8 Red face18 Severe itching?9 Elevated temp19 Involuntary contractions of muscles12 Bad all over20 Gas13 Loose, watery stools21 Head pain16 Sensation of stomach discomfort17 Feeling of distress or sufferingAPPLY YOUR KNOWLEDGEChoose the best answer to each of the following questions.1.Marcus Westerfield exhibits a positive test result on a Hemoccult fecal occult blood test. Dr. Diagnosis has decided to perform a flexible sigmoidoscopy on Marcus to assist in determining the cause of his bleeding. Marcus must sign a consent to treatment form before undergoing this procedure. Before he signs this form, Dawn Bennett, CMA (AAMA), must make sure that:A.Marcus has sanitized his handsB.A notary public is available to witness Marcus’s signatureC.Dr. Diagnosis has discussed all aspects of the procedure with MarcusD.Someone is available to drive Marcus home after the procedure2.After performing the flexible sigmoidoscopy on Marcus, Dr. Diagnosis dictates the results of the examination. Dawn transcribes the report and files it in Marcus’s medical record under this chart divider:A.History and PhysicalB.Laboratory/X-rayC.HospitalD.Progress Notes3.Michael Johnson is moving to Michigan. He calls the office and asks Dawn Bennett, CMA (AAMA), to transfer his medical record to his new physician. Dawn should:A.Explain to Michael that his medical record belongs to Dr. Diagnosis and cannot leave the office.B.Make a copy of the medical record and send it to Michael.C.Tell Michael that the information in a medical record is confidential and cannot be released.D.Ask Michael to come into the office and sign a release of medical information form.4. Eva North, a 52-year-old factory worker, comes to the office complaining of difficulty in breathing and persistent coughing. She smokes 2 packs of cigarettes per day and has tried everything to quit smoking. When the medical assistant is taking Eva’s symptoms, which of the following would be an appropriate way to communicate with Eva?A.Offer Eva some breath mints.B.Avoid eye contact so that Eva does not feel embarrassed about coughing so much.C.Tell Eva that heavy smoking can damage her alveoli, which can cause emphysema, a chronic obstructive pulmonary disease, and an eventual need oxygen for therapy.D.Observe that Eva is coughing a lot, and offer her a glass of water.5.Patricia McGhee comes to the office, and Dawn Bennett, CMA (AAMA), escorts her to an examining room. Dawn obtains Patricia’s vital signs and asks her what problem has brought her to the office. Patricia says that for the past 5 days she has been coughing, have been running a temperature, and has been short of breath. Of the following, which would be the best example of charting Patricia’s chief complaint?: Dyspneic, febrile, with : Patricia is sick.: Cough, fever, shortness of breath for 5 : Patricia is running a fever and coughing a lot. She is short of breath, especially in the morning. She has been feeling this way for the past 5 days.6. Dr. Diagnosis wants Dawn to check to see whether Patricia is allergic to penicillin. Dawn would find this information in Patricia’s health history under:A.Current IllnessB.Past historyC.Family historyD.Social history7.Dr. Diagnosis asks Dawn to administer a breathing treatment to Patricia. Which of the following represents the correct method for charting the breathing treatment?A.Chart the breathing treatment immediately after administering it.B.Use a no. 2 lead pencil to chart the breathing treatment.C.Chart the breathing treatment just before administering it.D.Have the office manager chart the breathing treatment.8.Patricia is prescribed medication for pneumonia. Two days later, she calls the office and says she feels sick to her stomach and vomits after taking her medication. Of the following, which would be the best example of charting this information in Patricia’s medical record?A.4/2/12 Nausea with medication. D. Bennett, CMA (AAMA)B.4/2/12 9:00 a.m. Called office. N&V after taking med. Reported sym to Dr. Diagnosis. D. Bennett, CMA (AAMA).C.4/2/12 9:00 a.m. N&V probably due to allergic reaction to the medication. Notified Dr. Diagnosis of the problem. D. Bennett, CMA (AAMA)D.4/2/12 9:00 a.m. Patricia called and said she vomits after taking her medication. I reported this information to Dr. Diagnosis right after he got back from lunch at the Red Lobster. D.B.9.Inoko Lin comes to the medical office complaining of a skin problem. She is from Japan and is attending college in the United States. Which of the following shows that Dawn Bennett, CMA (AAMA), is practicing cultural awareness?A.Bowing on greeting Inoko LinB.Speaking loudly so Inoko Lin can understand the conversationC.Asking Inoko Lin how she prefers to be addressedD.Asking Inoko Lin how to make chop suey10.Amy Grant is describing her symptoms to Dawn Bennett, CMA (AAMA). She states that her symptoms include a red, blistery rash; intense itching; nausea; and fatigue. Which of Amy’s symptoms is an objective symptom?A.Blistery, red rashB.Intense itchingC.NauseaD.FatigueVIDEO EVALUATION FOR CHAPTER 1: THE MEDICAL RECORDName: Directions:a.Watch the videos indicated.b.Mark each true statement with a T and each false statement with an F. For each false statement, change the wording of the question so that it becomes a true statement.Video: Procedure 1-2: Release of Medical Information____F___ 1.The information in a patient’s medical record can be read by anyone who is employed by the medical office. ____T___ 2.The patient must sign a consent form to release information from his or her medical record. ____T___ 3.The medical assistant witnesses the patient’s signature by signing the form in the appropriate space on the form. ____T___ 4.The medical assistant should release only the information indicated on the release of information form. ____T___ 5.The medical assistant must document the information that is being released in the appropriate space on the release form. ____T___ 6.The release of information form provides legal documentation that the patient gave permission for the release of his or her medical information. Video: Procedure 1-2: Preparing the Medical Record____T___ 1.A medical record is a written document of the important information regarding a patient. ____T___ 2.The medical record includes the patient’s health history, treatment, and progress. ____T___ 3.Each patient must sign a Notice of Privacy Practices acknowledgment form. ____F___ 4.A copy of the patient’s insurance card is required for proper identification of the patient. ____T___ 5.The medical assistant must enter the data on the patient registration form into the computer. ____T___ 6.The patient’s registration form should be placed in front of the medical record. Taking Patient SymptomsSupplemental Education for Chapter 1Following are examples of questions to ask the patient when analyzing patient symptoms.Problem 1Chief Complaints: Earache and fever for the past 2 days Questions:1.Which ear are you experiencing the symptoms in?2.What has your temperature been running?3.Describe the ear pain.4.Has the pain stayed the same or gotten worse?5.Are there any other symptoms you are experiencing, such as headache or fatigue?6.Has your hearing decreased in the affected ear?7.Have you been swimming recently?8.Have you had an ear infection before?9.Are you taking any medications to relieve the symptoms that you are experiencing?10.Has there been any discharge of pus or blood from your ear?11.Have you noticed any swelling of the outer ear?12.Are you allergic to any medications?13.On a scale of 1 to 10, rate the pain.14.Have you experienced any “popping” or a feeling of stuffiness in the ear?Problem 2Chief Complaints: Rash with itching that began 3 days ago1.Where is the rash located?2.Describe the rash.3.Are you experiencing any other symptoms, such as sore throat, fever, fatigue, or headache?4.Is the rash spreading or getting worse?5.Have you been recently exposed to unusual chemicals, plants, or animals?6.Have you been exposed to anyone with similar symptoms?7.Have you recently started taking any new medications?8.Are you taking any medications to relieve your symptoms?9.Do you have any itching in your eyes?Problem 3Chief Complaints: Pain during urination that began yesterdayDescribe the pain.Do you have back pain?Do you have a vaginal discharge?Are you experiencing any other symptoms, such as nausea, vomiting, or fever?Have you had a urinary tract infection (UTI) in the past year?Do you have to urinate more frequently?Are you taking any medications?Do you have any drug allergies?Do you have a new sexual partner?Problem 4Chief Complaints: Low back pain for the past months1.Describe the pain.2.On a scale from 1 to 10, rate your pain.3.Has the pain gotten worse or stayed the same?4.What were you doing when you first noticed the pain?5.Do you have other symptoms, such as weakness or numbness in your legs or pain running down the back of your legs?6.Have you been running a fever?7.Are you taking any medications for the pain?8.Does anything seem to make the pain worse, such as coughing, leaning forward, or bending over?Problem 5Chief Complaints: Sore throat and fever for the past 24 hours1.What has your temperature been running?2.Are your neck glands swollen or tender?3.Does it hurt only when you swallow?4.Have you been having any other symptoms, such as headache, stomachache, rash, or fatigue?5.Do you bring up any phlegm if you cough? If so, what color is it?6.Are you taking any medications for your symptoms?7.Do you have any ear pain or tenderness around your ear area?8.Is your neck stiff?9.Have you had close contact with a person with strep throat?Problem 6Chief Complaints: Chest pain that occurred this morning1.Is there pain now? If yes, is the pain in the middle of the chest and crushing, pressing, or radiating to the arm?2.Were there any other symptoms, such as sweating, difficulty breathing, nausea, or dizziness?3.Have you had these symptoms before?4.What were you doing when you noticed the chest pain?5.Is there a family history of heart disease?6.Have you had any recent episodes of light-headedness or shortness of breath?7.Does taking a deep breath make the pain worse?8.Are you taking any OTC or prescription medications?9.Do you have a history of heart disease or gastric problems?10.On a scale from 1 to 10, rate the pain.11.Describe the pain.12.Has your stress level increased recently?13.How much caffeine do you consume a day?14.Do you smoke or use tobacco products? ................
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