1. Home
  2. Flashcards
  3. Preview

BooK: "Computers in the Med. Off."--*NOTES*

  1. Subjective; info given by the pt...It incl's the foll documents:
    • a. Hx of HPI: {Hist. of Present Illness}
    • b. RPD: {Routine Personal Data}
    • c. PMH: {Personal & Med Hx}
    • d. FH: {Family Hx}
    • e. CC: {Chief Complaint}
    • f. SH: {Social Hx}
    • g. ROS: {Review of Sys}
  2. Objective; Dr's Exam & Test's incl's:
    • a. Phys Exam & Findings
    • b. Lab & X/Ray Reports
    • c. Dx'c & Prognosis
    • d. Tx
    • e. Progress Notes & Consultation frm other physicians
    • f. Condition @ the time of termination
  3. 2 wats of MR R organized in the Med Off:

    *I. Prob oriented MR {POMR}*
    • 1. POMR: contains a prob list
    • * POMR: uses a method known as SOAP

    • S: Subjecive
    • O: Objective
    • A: Assessment {DX}
    • P: Plan {TX}
  4. Two Wats of MR r organized in the Med Off

    *II. Source- oriented MR {SOMR}*
    • 2. Source oriented MR {SOMR}
    • Pt. info is arranged according 2 who supplies the data.

    • *Pt.
    • *Dr.
    • * Specialist
    • * Someone Else
  5. Creat'n a Pt's Chart:
    • 1. Manual Sys
    • 2. Computerized Sys
  6. Six C's of Charting:
    • 1. "Client's Word"
    • 2. "Clarity"
    • 3. "Completeness"
    • 4. "Conciseness"
    • 5. "Chronological Order"
    • 6. "Confidentiality"
  7. Mr. Filing~A filing sys is a method by which files R org'd...
    • 1. Alphabetical Sys
    • 2. Geographical Sys
    • 3. Subjective Sys
    • 4. Numeric Sys
    • 5. Phonetic Sys
    • 6. Computerized Sys
  8. HIPAA
    HIPAA: Health Ins Portability Accountability Act 1996
  9. HIPAA: Privacy Rule
  10. HIPAA: Security Rule
  11. HIPAA: Code Transaction Set
  12. An Internist specializes in treating...
    • a.) Pt's of all ages
    • b.) Adults
    • c.) Diseases of the Organs
    • d.) Families
  13. Phys's responsible 4 overseeing pt's overall health care & 4 referring pt's 2 specialists r known as...
    • a.) Family Practitioners
    • b.) Primary Care Phys's
    • c.) Internists
    • d.) Family Care Phys's
  14. Generally, wht's not a part of the pt's Med. Rec.???
    • a.) Ins. Correspondence
    • b.) Chart Notes
    • c.) Pt. Info.
    • d.) Remittance Advice (RA)
  15. The HIPAA security standards r divided in/2 wht 3 Categories???...
    • I. Administrative
    • II. Physical
    • III. Technical
  16. The O in SOAP refers 2...
    • a.) Obstetrical
    • b.) Observation
    • c.) Objective
    • d.) Ordinary
Author
BrowneeE
ID
76935
Card Set
BooK: "Computers in the Med. Off."--*NOTES*
Description
CHAP I & II: Exam Review!!!
Updated

  1. Home
  2. Flashcards
  3. Preview