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Decks in this class (19)

Chapter 1: Purpose of Medical Records
Why are medical records important,
Why the documentation of the pati...,
What are the first two reasons of...
8  cards
Chapter 1: Ownership of Medical Records
Who owns medical records
1  cards
Chapter 1: Users of Medical Records
Insurers use medical records use ...,
Why does coders review records an...,
Why do clinical researchers analy...
6  cards
Chapter 1: Release of Information (ROI)
To protect patients confidentiali...,
Who usually designates a staff me...,
What is the first thing that the ...
5  cards
Chapter 1: Retention and Disposal
What is the storage of medical re...,
Who generally govern how long to ...,
The mandated retention periods en...
7  cards
Chapter 2: Types of Medial Reports
What are the first medical reports,
What are the second medical reports,
What are the third medical reports
3  cards
Chapter 2: Process Notes
Process notes are also known as,
What does progress notes do,
Progress notes are entered chrono...
6  cards
Chapter 2: History & Physical (H&P)
What does history physical h p pr...,
What does all hospital patients get,
All hospital patients get a histo...
6  cards
Chapter 2: Sections of an H&P
What are the first 4 sections of ...,
What are the second 4 sections of...,
What are the third 4 sections of ...
15  cards
Chapter 2: Discharge Summary
What is the discharge summary,
What does the discharge summary i...,
What is the hospital course secti...
4  cards
Chapter 2: Consultation
When does consultation occurs,
Can a consultation be requested f...,
Consultations should follow certa...
7  cards
Chapter 2: Operative Report
What describes a surgical procedu...,
What includes the operative report,
Does the operative report can als...
3  cards
Chapter 2: Pathology Report
What does pathology report describes,
What does gross examination mean,
What does gross examination involve
4  cards
Chapter 2: Radiology Report
What does x rays uses to produce ...,
What does computerized tomography...,
What does magnetic resonance imag...
8  cards
Chapter 2: Laboratory Report
Where does outside labs send labo...,
Despite differences in the presen...,
What does all certain elements ma...
6  cards
Chapter 2: flow Sheets
What is a flow sheet,
What does the flow sheet data may...,
What does flow sheets structures ...
14  cards
Chapter 3: Sections of the POMR
The problem oriental medical reco...,
Pomr stores information in a way ...,
Where is the patient s problem found
6  cards
Chapter 3: SOAP Notes
What does the problem oriented me...,
Soap is an acronym for,
What is subject in soap acronym
6  cards
Chapter 4: Documentation Standards
What does the national committee ...,
Does each page in the record shou...,
All entries are authenticated by
10  cards

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Medical Assistant Lesson 9

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