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68W Limited Primary Care UPDATED Questions and CORRECT
Answers
1. DD Form 689 Individual sick call slip that initiates the sick call process
Used for patient who requests or receives medical/dental evaluation or treatment
at an Army Medical Treatment Facility (MTF)
used as a means of communication between medical personnel and the patient's
commander
2. SF 600 Chronological Record of Medical Care
form used to document the chronological record of the patient's treatment
Should include:
- Date and time of visit
- Medical Treatment Facility
- Signature of person making entry
3. Correction proce- Draw a single line through the information, write "Error," and your initials
dures for an en-
try error If you have finished the documentation and decide later information needs to be
changed:
- add correct information
- reason for change
- date and initial
- Do not skip lines or leave any spaces above signature
4. HIPAA Health Insurance Portability and Accountability Act
a federal law protecting the privacy of patient-specific health care information
5.
,\
68W Limited Primary Care UPDATED Questions and CORRECT
Answers
Access to pa- - the patient
tient's medical in- - patient care personnel
formation may - medical researcher
be given too... - medical educators
6. Exceptions for - if access is court ordered by law
those that can ac- - if access if needed for hospital accreditation
cess a patient's - if access is authorized by the patient via a written document
medical informa-
tion are...
7. Disclosure of the PA or the patient administrator (PAD)
medical informa-
tion is handled
by...
8. History Taking 1) Observation - begins when patient walks through the door
Techniques
2) Listening - will help you find out the problem
3) Open-ended questions - helps you get more complete and accurate informa-
tion
4) Provider obstacles - keep a good attitude and assume every patient has a
legitimate complaint
5) Patient obstacles - patient's w/o medical experience will very often request
specific diagnostic studies, therefore, we must gain their trust
6) Obtain a thorough history
7) Maintain an index of suspicion
8) Consider the mechanism of injury
, 9. Triage Triage is about looking for signs and symptoms that could lead to serious illness
or even death
You may decrease the likelihood of overlooking these conditions by maintaining an
index of suspicion based on the presenting symptoms and by obtaining accurate
vital signs on each and every patient
10. Techniques for - Obtain the chief complaint
Identifying Criti- - Identify patients with signs and symptoms that have increased potential for
cally Ill Patients complications
- promptly obtain vital signs
- perform a physical exam and report findings to medical provider
11. Initiating the Sick 1) Patient will obtain a DD Form 689., an individual sick slip, which will ensure
Call Process accountability of the soldier is maintained both at the MTF and with patient's unit
2) a combat medic will be assigned to sign in all patients in a daily disposition log
3) the combat medic will retrieve the patient's medical record and initiate an entry
on a SF 600, or the Chronological Record of Medical Care
4) Combat medic will take the patient's vital signs and initiate an entry on SF 600
in a SOAP format by asking for the patient's HPI
5) Physical examination will be performed by the Medical Oflcer
12. Subjective Infor- Subjective information is information that the patient tells you. It is what the patient
mation reports he feels or understands as the problem. It is information that you cannot
necessarily find in an examination.
- age, sex, race and first day of last menstrual period (FDLMP)
- chief complaints
68W Limited Primary Care UPDATED Questions and CORRECT
Answers
1. DD Form 689 Individual sick call slip that initiates the sick call process
Used for patient who requests or receives medical/dental evaluation or treatment
at an Army Medical Treatment Facility (MTF)
used as a means of communication between medical personnel and the patient's
commander
2. SF 600 Chronological Record of Medical Care
form used to document the chronological record of the patient's treatment
Should include:
- Date and time of visit
- Medical Treatment Facility
- Signature of person making entry
3. Correction proce- Draw a single line through the information, write "Error," and your initials
dures for an en-
try error If you have finished the documentation and decide later information needs to be
changed:
- add correct information
- reason for change
- date and initial
- Do not skip lines or leave any spaces above signature
4. HIPAA Health Insurance Portability and Accountability Act
a federal law protecting the privacy of patient-specific health care information
5.
,\
68W Limited Primary Care UPDATED Questions and CORRECT
Answers
Access to pa- - the patient
tient's medical in- - patient care personnel
formation may - medical researcher
be given too... - medical educators
6. Exceptions for - if access is court ordered by law
those that can ac- - if access if needed for hospital accreditation
cess a patient's - if access is authorized by the patient via a written document
medical informa-
tion are...
7. Disclosure of the PA or the patient administrator (PAD)
medical informa-
tion is handled
by...
8. History Taking 1) Observation - begins when patient walks through the door
Techniques
2) Listening - will help you find out the problem
3) Open-ended questions - helps you get more complete and accurate informa-
tion
4) Provider obstacles - keep a good attitude and assume every patient has a
legitimate complaint
5) Patient obstacles - patient's w/o medical experience will very often request
specific diagnostic studies, therefore, we must gain their trust
6) Obtain a thorough history
7) Maintain an index of suspicion
8) Consider the mechanism of injury
, 9. Triage Triage is about looking for signs and symptoms that could lead to serious illness
or even death
You may decrease the likelihood of overlooking these conditions by maintaining an
index of suspicion based on the presenting symptoms and by obtaining accurate
vital signs on each and every patient
10. Techniques for - Obtain the chief complaint
Identifying Criti- - Identify patients with signs and symptoms that have increased potential for
cally Ill Patients complications
- promptly obtain vital signs
- perform a physical exam and report findings to medical provider
11. Initiating the Sick 1) Patient will obtain a DD Form 689., an individual sick slip, which will ensure
Call Process accountability of the soldier is maintained both at the MTF and with patient's unit
2) a combat medic will be assigned to sign in all patients in a daily disposition log
3) the combat medic will retrieve the patient's medical record and initiate an entry
on a SF 600, or the Chronological Record of Medical Care
4) Combat medic will take the patient's vital signs and initiate an entry on SF 600
in a SOAP format by asking for the patient's HPI
5) Physical examination will be performed by the Medical Oflcer
12. Subjective Infor- Subjective information is information that the patient tells you. It is what the patient
mation reports he feels or understands as the problem. It is information that you cannot
necessarily find in an examination.
- age, sex, race and first day of last menstrual period (FDLMP)
- chief complaints
