Medical records/ documentation/abbreviations

Record information about a patient’s medical history

• Medical information

• Medical document

• Guidelines

• Application

Medical documents may be used in a court of law

• True

• False

Medical Documents contain information such as:

name, sex, age, Social Security number, contact information

• Yes

• No

• Partially correct

_________ _________ provides us with the previous treatments the patient has undergone in the past

• Disease Diagnosis

• Charting

• Transcription information

• Medical history

In addition to being essential documents for patient care management, patient records are used for

• providing patient education

• emergency contact information

• Data that is submitted to the state

The abbreviation p.o means:

• police officer

• everyday

• by mouth

• post operation

the abbreviation Rm means:

• roommate

• room

• range of motion

• at bedtime

Medical history should __________ be altered

• often

• sometimes

• never

• always

All of the above are guidelines for reporting medical history except:

• always include date and time

• record information as how you perceive it to be

• repeat information back to patient

• ask questions if patient is unclear

HITECH act is...

• the privacy and security concerns associated with the electronic transmission of health information

• review of systems: Checklist of symptoms

• inaccurate and possibly deadly treatment