What is the HIPAA privacy rule? - Answers -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? - Answers 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)? - Answers Problem Oriented Record
What are the four categories of the SOAP progress note? Name them and what they
each contain. - Answers Subject data, objective data, assessment, plan
What does it mean for a medical assistant to witness a signature? - Answers 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? - Answers 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? - Answers
medical impression, provisional diagnosis, preliminary diagnosis, or tentative diagnosis
Lab reports contain what type of information? - Answers specific problems are to be filed with other
reports related to the problem
What is a consultation report? - Answers 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? - Answers •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? - Answers 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? - Answers 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? - Answers refers to treatment for the correction of a speech impairment
resulting from birth, disease, injury, or previous medical treatment.
define inpatient - Answers 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? - Answers 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? - Answers report containing a description of tissue samples removed from
the body
What is the discharge summary report? - Answers Report that is required for all patients who leave the
health care facility summarizing patient's condition during his/her stay.
What is the chief complaint (CC)? - Answers identifies the patient's reason for seeking care—that is, the
symptom that is causing the patient the most trouble.
What are the guidelines in obtaining and recording the CC? - 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 the past medical history? - Answers The patient's previous diseases, injuries, and operations
What is family history? - Answers Review of health status of patient's blood relatives