MA500 Exam #2 Questions And Well Detailed 100% Explained Answers.

Review the correct examples of chief complaints - correct answers- Burning during urination that has lasted for 2 days - Pain in the shoulder that started 2 weeks ago - Shortness of breath for the past month What is the primary purpose of the rule? - correct answers provide patients w/ better control over the use and disclosure of their health information What is the acronym for the progress note charting in the problem oriented record (POR)? - correct answers SOAP What are the four categories of the SOAP progress note? Name them and what they each contain. - correct answers1. Subjective data: obtained from the patient 2. Objective data: obtained by observation, physical examination, laboratory & diagnostic tests 3. Assessment: the physician's interpretation of the current condition based on the analysis of the subjective & objective data 4. Plan: proposed treatment for the patient What does it mean for a medical assistant to witness a signature? - correct answers that the MA verified the patient's identity & watched the patient sign the form What is a health history? - correct answers a collection of subjective data about a patient Before there is enough information, what terms might the physician use? - correct answers the provider uses terms such as medical impression, provisional diagnosis, preliminary diagnosis, or tentative diagnosis Lab reports contain what type of information? - correct answers related to specific problems that are filed together in a paper-based medical record and accessed from 1 tab in EHR What is a consultation report? - correct answersa narrative report of an opinion about a patient's condition by a practitioner other than the attending physician or primary care provider What type of services are offered through home health care? - correct answerscardiac home care, intravenous (IV) therapy, respiratory therapy, pain management, diabetes management, rehabilitation, and material childcare Physical therapy involves what? - correct answersinvolves the use of therapeutic exercise, thermal modalities, cold, hydrotherapy, electrical stimulation, massage, & other physical agents to restore function & promote healing after an illness or injury. Occupational therapy helps with what? - correct answersa patient learns new skills to adapt to a physically, developmentally, emotionally, or mentally disabling condition Speech therapy refers to what? - correct answersrefers to treatment for the correction of a speech impairment resulting from birth, disease, injury, or previous medical treatment Define inpatient? - correct answersrefers to a patient who has been admitted to the hospital for at least one overnight stay What is an operative report? - correct answers- it is completed for all patients who have undergone a surgical procedure - the report describes the surgical procedure & and must be completed and signed by the surgeon who performed the operation What is a pathology report? - correct answersgenerated if tissue was removed for microscopic examination What is the discharge summary report? - correct answersa summary of the significant events of a patient's hospitalization When is the health history taken? - correct answerstaken for each new patient as a baseline/reviewed & updated annually What are the guidelines in obtaining/recording the CC? - correct answers- An open-ended question should be used to elicit the CC from the patient: What seems to be the problem? How can we help you today? What brings you to the doctor today? - The CC should be limited to one or two symptoms and should refer to a specific rather than a vague symptom - The CC should be recorded concisely and briefly, using the patient's own words as much as possible - The duration of the symptom (onset) should be included in the CC - The medical assistant should avoid using names of diseases or diagnostic terms to record the CC What is HIPAA privacy rule? - correct answersA federal law consisting of several components, one which contains provisions to protect a patient's privacy, known as the HIPAA privacy rule What is the chief complaint (CC)? - correct answersa statement of the most important symptoms for which a patient is seeking care What is the past medical history? - correct answersa review of the patient's past medical status What is family history? - correct answersa review of the health status of the patient's blood relatives What is the review of systems (ROS)? - correct answersROS is a systematic review of each body system to detect any symptoms that have not yet been revealed What are the five guidelines for documenting in a patient's record? - correct answers1. Check the name and date of birth on the EHR or paper chart before making an entry to ensure you have the correct record. From a legal standpoint, a procedure not documented was not performed. 2. Document information accurately in a logical order, using clear and concise phrases. (brief, capital and end w/ a period, and abbreviations: CHART BELOW) 3. Spell correctly. Correct spelling is essential for accuracy in documentation. A dictionary should be consulted as needed. 4. Document immediately after performing a procedure. When a procedure has been performed, it should be documented without delay. The name of the provider who ordered the procedure or who is going to be cosigning the note must be included. If a time lapse occurs between performing the procedure and documenting it, the medical assistant may not remember certain aspects of the procedure, such as the results of the treatment or the patient's reaction. 5. Procedures should never be documented in advance. The individual performing the procedure should be the one to document it after the procedure has been completed. Why is it important to document and sign all necessary instructions? - correct answers- b/c the MA functions as a signature witness - protects the physician legally in the event that the patient fails to follow the instructions and causes further harm or damage to a body part What is data? - correct answersRaw, unorganized facts about subject matter presented to the computer for processing What is input? - correct answersThe transfer of data to the computer for processing or data that has been entered into the computer What is processing? - correct answersThe manipulation and reorganization of data according to the instructions in a program. What is output? - correct answersThe transfer of processed data back to the user. What is an output device? Give an example. - correct answersconverts the electronic code into a form that can be understood by the user. common devices are the monitor & printer What is system software? - correct answersmade up of a group of special programs that control or maintain the operations of computer What is an operating system? give an example - correct answersA system software that performs tasks required by the computer to function ex: Windows ( Microsoft Corporation) What is a spreadsheet? - correct answersan electronic ledger designed to perform mathematic calculations quickly The data in EHR systems can link to what large pool of information? - correct answerspatient records/transactions, diagnosis/procedure codes, insurance carriers but also provides the ability to add new information, modify existing information, and delete unneeded information Many physicians use voice recognition software to do what? - correct answersdictate progress notes and reports To prevent overheating of the main computer unit, what care should be taken? - correct answers- main unit should not be placed near a window or other areas that receive direct sunlight - to prevent overheating, the ventilation slots on the main unit should not be obstructed. How should the monitor be positioned to prevent back and neck tension? - correct answersplaced directly in front of the user and at an arm's length distance when sitting back in a chair, so that the top of the monitor is approximately 2 to 3 inches above eye level Eye muscles must work harder to focus on near objects. How can eye strain be avoided while working on the computer? - correct answersFocus your eyes on a distant object (more than 20 feet away) to prevent eyestrain What is privacy filter? - correct answersThey reduce glare as well as increase privacy of screen information by bullying or blacking out the screen image to anyone who is not directly in front of it What type of material should be used to clean an LCD monitor? - correct answers- with a lint-free cloth - no paper towels/tissues b/c they can scratch the screen - If the dry cloth does not remove all soil, do not press harder because the screen can be damaged (use distilled water on a soft cloth or commercial wipes or cleaners for LCD screens) - Do not use cleaners that contain chemicals (ethyl alcohol, acetone) b/c these can discolor the screen - cleaner should not be applied directly to the screen or sprayed on the screen because it may run down into the inside of the case and damage the electrical circuits. - Keeping the screen clean helps prevent distracting reflections. Grime can be removed from a keyboard using what? - correct answersshould be cleaned w/ an antiseptic wipe or a slightly damp, lint-free cloth What is one type of an optical disc? - correct answersa storage device that stores data using laser technology ex: compact disc (CD) DVD What is a USB flash drive? - correct answers- a portable storage device that consists of a small circuit board in a plastic case - it is called a flash drive b/c it uses flash memory other terms for flash drive are: jump drive/thumb drive What is the audit trail used for? - correct answersProtect Patient Privacy What software application can be used to access the World Wide Web? - correct answersInternet Explorer, Google Chrome, Mozilla Firefox What does the messaging system within the EHR allow? - correct answersallows secure communications among healthcare providers and gives the ability to link directly to clinical & laboratory data regarding patients What is patient portal? - correct answers- an online application that allows patients to interact w/ and communicate with their healthcare providers - able to access laboratory reports/health education resources, there is often a secure e-mail system allowing patients to communicate directly w/health care providers and other staff members by secure e-mail What is e-prescribing? - correct answersthe process of sending and receiving prescriptions by electronic means