MA 500 Study Outline #2 Multiple Choices Questions And Verified Accurate Answers.

What is the HIPAA privacy rule? - correct answers The acronym HIPAA stands for the Health Insurance Portability and Accountability Act. It's a federal law to protect a patient's privacy. What is the primary purpose of the rule? (HIPPA) - correct answers The primary purpose of this rule is to provide patients with better control over the use and disclose of their health information. What is the acronym for the progress note charting in the problem oriented record (POR)? - correct answers The acronym for this method of documentation is SOAP, and this method of creating progress notes is now widely used in all medical record formats. What are the four categories of the SOAP progress note? Name them and what they each contain. - correct answers• Subjective data: Subjective data obtained from the patient • Objective data: Objective data obtained by observation, physical examination, and laboratory and diagnostic tests • Assessment: The physician's interpretation of the current condition based on analysis of the subjective and objective data • Plan: Proposed treatment for the patient What does it mean for a medical assistant to witness a signature? - correct answers Witnessing a signature means only that the medical assistant verified the patient's identity and watched the patient sign the form. What is a health history? - correct answersA collection of subjective data about the patient. Before there is enough information, what terms might the physician use? - correct answersThe provider uses terms such as medical impression, provisional diagnosis, preliminary diagnosis, or tentative diagnosis. Lab reports contain what type of information? - correct answerslaboratory data obtained at the initial visit and the physical examination findings are considered part of the database, whereas laboratory reports related to specific problems are to be filed with other reports related to the problem. What type of services are offered through home health care? - correct answersspecialized services available through home health care include cardiac home care, intravenous (IV) therapy, respiratory therapy, pain management, diabetes management, rehabilitation, and maternal-child care. Physical therapy involves what? - correct answersPhysical therapy 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? - correct answersHelps 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? - correct answersSpeech therapy refers to treatment for the correction of a speech impairment resulting from birth, disease, injury, or previous medical treatment. Define inpatient - correct answersThe term inpatient refers to a patient who has been admitted to the hospital for at least one overnight stay. What is an operative report? - correct answersMust 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? - correct answersIf tissue was removed for microscopic examination, a pathology report will also be generated. What is the discharge summary report? - correct answersA brief (usually one-page) summary of the significant events of a patient's hospitalization completed & signed by the attending physician. What does a discharge summary include? - correct answersPatient's illness, course of treatment, and response to treatment, and the condition of the patient at the time of discharge from the hospital. What is a heath history? - correct answersA collection of subjective health data obtained by interviewing. When is the health history taken? - correct answersA thorough history is taken for each new patient as a baseline. Taken before the physical examination is performed. What is the chief complaint (CC)? - correct answersThe chief complaint (CC) 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? - 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 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 answersreview 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. 2. Document information accurately in a logical order, using clear and concise phrases. 3. Spell correctly. Correct spelling is essential for accuracy in documentation. 4. Document immediately after performing a procedure. 5. Procedures should never be documented in advance. Why is it important to document and sign all necessary instructions? - correct answersMA functions as a signature witness & this 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 answersA general term used to describe the raw, unorganized facts presented to the computer for processing. What is input? - correct answersTransfer of date to the computer for processing. Input includes both the entering of data into the computer and the conversion of it into an electronic form that can be understood by the computer. What is processing? - correct answersHandling and arranging of the electronic data by the computer to a program. Data undergos some type of manipulation or change to produce useful information. What is output? - correct answersOutput is the transfer of usable information back to the user What is an output device? - correct answersThe output device converts the electronic code into a form that can be understood by the user. Example of output device: - correct answersMonitor and the printer What is system software? - correct answersIs made up of a group of special programs that control or maintain the operations of a computer. What is an operating system? - correct answersThe operating system is installed on the hard disk of the computer and is automatically loaded into the computer's main memory when the computer is turned on. Operating system example: - correct answersAn example of an operating system frequently used in the medical office is Windows (Microsoft Corporation). What is a spreadsheet? - correct answersAn electronic ledger designed to perform mathematical calculations quickly. The data in EHR systems can link to what large pool of information? - correct answersThe medical practice database can be thought of as a large pool of information that the computer can access in a multitude of ways according to the task being performed. Many physicians use voice recognition software to do what? - correct answersMany physicians now use this method to dictate progress notes and reports. To prevent overheating of the main computer unit, what care should be taken? - correct answersThe main unit should not be placed near a window or other areas that receive direct sunlight. In addition, 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 answersThe monitor should be placed directly in front of the user and at an arm's length distance when sitting back in a chair. This position provides the most comfortable viewing distance. The monitor should be positioned so that the top of the monitor is approximately 2 to 3 inches above eye level. Eve's 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 eye strain. It is also important to blink frequently while you work to lubricate and moisten the eyes to prevent them from drying out. What is a privacy filter? - correct answersReduce glare as well as increase privacy of screen information by blurring 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 answersWipe it gently with a soft, lint-free cloth. Grime can be removed from a keyboard using what? - correct answersShould be cleaned with an antiseptic wipe or a slightly damp, lint-free cloth. What is one type of an optical disc? - correct answersOne type of optical disc is a compact disc (CD), which can hold about 650 MB of data. What is a USB flash drive? - correct answersA portable storage device that consists of a small circuit board in a plastic case. Other terms for a flash drive include a jump drive and a thumb drive What is the audit trail used for? - correct answersA log is stored and can be retrieved to detect irregularities. Keeping track of each person that accessed data in the medical record. This capability helps protect patient privacy. What software application can be used to access the World Wide Web? - correct answersThe World Wide Web is a series of documents, or webpages, that can be accessed by a software application called a Web browser, such as Internet Explorer, Google Chrome, or Mozilla Firefox. What does the messaging system within the EHR allow? - correct answersIt allows secure communications among health care providers and gives the ability to link directly to clinical and laboratory data regarding patients. What is a patient portal? - correct answersThis is an online application that allows patients to interact with and communicate with their health care providers. What is e-prescribing? - correct answersTransmission of prescriptions directly to pharmacies electronically usually accomplished as a function of an EHR. E-prescribing is one of the quality measures used as part of the Medicare Quality Payment program. Is it ever okay to share your password with a coworker? - correct answersThe medical assistant should not share his or her password with anyone else. What does an effective password consist of? - correct answersEffective passwords include random series of digits, letters, and symbols rather than English words, telephone numbers, or other combinations that have meaning What is antivirus software also known as? - correct answersKnown as utility program. What is a computer virus? - correct answersThe term computer virus refers to software designed to penetrate a computer or network without consent. A computer virus can access information and/or cause damage. What is a firewall? - correct answersA system that protects a computer network from unauthorized access by users on its own network or another network, such as the internet. What is a backup? - correct answersA duplicate copy of a program or data kept for reference in case the original is damaged, lost, or destroyed. What is used for disposing of confidential documents? - correct answersOffices should also have a paper shredder for disposing of confidential documents. What are some examples of confidential documents from your text? - correct answersAlthough medical records must be maintained indefinitely, old telephone logs, old payroll records, canceled checks more than 7 years old, and minutes of practice management meetings. Any documents containing patient information that has been scanned in EMR should be shredded. What types of hand hygiene items are available in every examination room? - correct answersSink, soap , paper towel di