Rated A+
What is the HIPAA privacy rule? ANS -protects individuals' medical records and other personal
health information, including transfer of electronic records
-sets limits and conditions on the uses and disclosures allowed without patient authorization - only
necessary information is disclosed
-gives patients rights concerning the examination and copying of their health records and to request
corrections
What is the primary purpose of the HIPAA privacy rule? ANS to rectrict the circumstances in
which an individual's protected health info may be used.
What is the acronym for the progress note charting in the problem oriented record
(POR)? ANS Problem Oriented Record
What are the four categories of the SOAP progress note? Name them and what they
each contain. ANS Subject data, objective data, assessment, plan
What does it mean for a medical assistant to witness a signature? ANS only that the medical
assistant verified the patient's identity and watched the patient sign the form; it does not mean that
the medical assistant is attesting to the accuracy of the information provided.
What is a health history? ANS A collection of subjective data that provides a detailed profile of
the patient's health status
Before there is enough health history information, what terms might the physician use? ANS
medical impression, provisional diagnosis, preliminary diagnosis, or tentative diagnosis
Lab reports contain what type of information? ANS specific problems are to be filed with other
reports related to the problem
, What is a consultation report? ANS A narrative report of a clinical opinion about a patient's
condition by a practitioner other than the primary physician, known as a consultant. The consultant is
usually a specialist in a certain field of medicine
What type of services are offered through home health care? ANS •Observations and evaluations
• Type of care or service provided
• Instructions given to the patient on medications
• Safety measures recommended for the home
• Diet
• Activities permitted
Phvsical therapv involves what? ANS involves the use of therapeutic exercise, thermal
modalities, cold, hydrotherapy, electrical stimulation, massage, and other physical agents to restore
function and promote healing after an illness or injury
Occupational therapy helps with what? ANS helps a patient learn new skills to adapt to a
physically, developmentally, emotionally, or mentally disabling condition. This enables the patient to
perform activities of daily living and to achieve as much independence as possible.
Speech therapy refers to what? ANS refers to treatment for the correction of a speech impairment
resulting from birth, disease, injury, or previous medical treatment.
define inpatient ANS Inpatient is a person who is admitted to the hospital and stays overnight or
for an indeterminate amount of time, usually several days or weeks.
What is an operative report? ANS must be completed for all patients who have undergone a
surgical procedure. This report describes the surgical procedure and must be completed and signed by
the surgeon who performed the operation
What is a pathology report? ANS report containing a description of tissue samples removed from
the body