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CORRELATION
To show a mutual relationship
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DIAGNOSIS
The determination of the nature\ cause of a disease.
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DISCERNIBLE
To see or understand a difference between two things.
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INTEGRAL
Being an indispensable part of a whole.
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MEDICAL RECORD
A complete set of information put down in writing to authenticate evidence of facts and events.
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MEDICAL REPORT
A permanent legal document formally stating the results of an examination.
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OBJECTIVE (info)
Preceptible to the observer\external senses (i.e. Dr's conclusions).
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OBSERVATION
An inference from what has been seen or heard.
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PROFICIENCY
Competency as a result of training & experience.
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PROGNOSIS
The forecast of the outcome of a disease\injury.
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PROGRESS NOTES
Records of patient visits, phone calls, progress & treatment that are inserted into the pts. chart.
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SIGN
Any objective evidence of disease discoverable by a Dr. on examination of a patient.
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SUBJECTIVE
Findings perceptible only by the affected person.
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SYMPTOM
Any perceptible change in the body or its functions (Indicating disease or illness).
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Earache x 3 days
Subjective
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Tonsillectomy
Subjective & Objective
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Mother died at age 68
Subjective
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Appendectomy at age 12
Subjective
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Patient has Blue Cross/Blue Shield insurance
Subjective
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Address Change
Subjective
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Mastectomy
Objective & Subjective
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What is the difference between a medical report and a medical record?
- Report is a single document.
- Record is a complete set of information.
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The determination of a disease is known as the
Diagnosis
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The study of the causes of origin of a disease is known as
Etiology
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Forcasting the outcome of the diagnosis
Prognosis
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A sign is_____________ information.
Objective
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A symptom is _____________ information.
Subjective
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SOAP is an acronym for
Subjective, Objective, Assessment, Plan
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Write out the proper procedure for correcting an error in a patient's chart.
Draw a single line through the error, write word error, date and initial.
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List three benefits of shingling.
- Saves space
- Prevents loss of records
- Allows for the most recent report to be readily available (test results, x-ray reports, urinalysis reports)
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The SOAP approach of writing progress notes is known as the _____ method of record keeping.
traditional
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Whether you shingle or not, how should reports be placed in a patient's chart.
The most recent report is always placed on top.
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List three things medical records are used for:
- Patient education
- Research
- Evaluating quality of treatment
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What should be known about the patient record.
The patient record is a legal document, and always kept confidential.
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Congenital means ___________. List examples.
- at birth
- ex. down syndrome, cleft lip
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Are congenital defects considered subjective or objective?
both subjective and objective
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What should be known about the patient's chart upon completion of treatment?
Know that a physician should always chart the condition of a patient upon termination of treatment and this information is considered objective.
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What is a Pocket Call Record?
A notebook which a physician carries to out of office visits.
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What should be done before any transcribed notes or laboratory reports are placed in a patient's medical record?
The Physician must initial them.
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What does the acronym POMR stand for?
Problem Oriented Medical Record
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Know the difference between percussion, inspection, palpation, and ausculatation.
- Percussion: tap on the body
- Inspection: observation
- Palpation: feel with hands
- Auscultation: listen to sounds
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How does the correction of a handwritten entry differ from that of a typewritten entry?
- The corrrections are the same.
- Draw a single line through the error, write word error, date and initial.
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Amputation
Objective & Subjective
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Pain with urination
Subjective
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Abnormal lung sounds
Objective
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Tubes in Ear
Objective & Subjective
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Down Syndrome
Objective & Subjective
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Occult blood in stool
Objective
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Shortness of breath
Objective & Subjective
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Runny nose
Objective & Subjective
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Visible blood in stool
Subjective
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Condition at time of termination of treatment
Objective
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Diabetic maternal grandmother
Subjective
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