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Instructor’s Resource Manual
Chapter 1: The Medical Record
Key Term Assessment
1. Q / 11. S2. E / 12. H
3. B / 13. K
4. N / 14. L
5. R / 15. T
6. J / 16. O
7. I / 17. C
8. P / 18. M
9. A / 19. D
10. F / 20. G
Evaluation of Learning
1. List three functions of the medical record.
The physician uses the information in the medical record as a basis for making decisions regarding the patient’s care and treatment; it serves to document the results of treatment and the patient’s progress and provides an efficient and effective method by which information can be communicated to authorized personnel in the medical office; it also serves as a legal document.
2. What is the meaning of the acronym HIPAA?
Health Insurance Portability and Accountability Act.
3. What is the purpose of the HIPAA Privacy Rule?
To provide patients with more control over the use and disclosure of their health information.
4. Who must comply with HIPAA?
All health care providers, health plans, and health care clearinghouses (e.g., billing services) that use, store, maintain, or transmit health information.
5. What is a Notice of Privacy Practices?
A written document provided to patients that explains how their protected health information will be used and protected by the medical office.
6. List examples of when HIPAA does not require written consent for the use or disclosure of a patient’s health information in the following categories:
a. Treatment: Patient referral to a specialist, emergency care at a hospital, and laboratory performing tests on a patient.
b. Payment: Determination of eligibility for insurance benefits, reviewing services provided for medical necessity, and utilization review activities.
c. Health care operations: Quality assessment activities, contacting patients with information about care or treatment, employee review activities, and training health care students.
7. What two general categories of information are included on a patient registration record?
Demographic and billing information.
8. List three uses of the health history.
To determine the patient’s general state of health, to arrive at a diagnosis and prescribe treatment, and to observe any change in a patient’s illness after treatment has been instituted.
9. What is the purpose of the physical examination?
To provide objective data about the patient that assists the physician in determining the patient’s state of health.
10. What is the purpose of progress notes?
To document the patient’s health status from one visit to the next.
11. List three categories of medication that may be included in a medication record.
Prescription medications, OTC medications, and medication administered at the medical office.
12. What is the purpose of home health care?
To minimize the effect of disease or disability by promoting, maintaining, and restoring the patient’s health.
13. List five examples of home health services.
Cardiac, infusion (IV) therapy, respiratory therapy, pain management, diabetes management, rehabilitation, and maternal-child care.
14. What is the purpose of a laboratory report?
To relay the results of laboratory tests to the physician to assist in diagnosis and treatment of disease.
15. List five examples of diagnostic procedure reports.
Electrocardiogram, Holter monitor, sigmoidoscopy, colonoscopy, spirometry, radiology, and diagnostic imaging.
16. What is the purpose of a therapeutic service report?
To document the assessments and treatments designed to restore the patient’s ability to function.
17. What is the difference between physical therapy and occupational therapy?
Physical therapy involves the use of physical agents to restore function and promote healing after an illness or injury; occupational therapy helps the patient learn new skills to adapt to a disabling condition.
18. List examples of physical agents used in physical therapy.
Therapeutic exercise, thermal modalities, cold, hydrotherapy, electrical stimulation, and massage.
19. What is speech therapy?
Treatment to correct a speech impairment resulting from birth, disease, injury, or prior medical treatment.
20. What is the purpose of an operative report?
To describe a surgical procedure performed on a patient.
21. What is the purpose of the discharge summary report?
To provide information to the patient’s (family) physician for the continuity of future care and to respond to authorized requests for information regarding a patient’s hospitalization.
22. What is included in a pathology report?
A macroscopic and microscopic description and diagnosis of tissue removed from a patient during surgery or a diagnostic procedure.
23. Why is a copy of an emergency room report sent to the patient’s family physician?
For the purpose of providing follow-up care.
24. When is a consent to treatment form required?
For all surgical operations and nonroutine diagnostic and therapeutic procedures performed in the medical office.
25. What is the purpose of a consent to treatment form?
To provide written evidence that the patient agrees to the procedure(s) listed on the form.
26. What information must the patient receive before signing a consent to treatment form?
The nature of the patient’s condition, the nature and purpose of the recommended procedure, an explanation of any risks involved with the procedure, any alternative treatments or procedures available, the likely outcome (prognosis), and risks involved with declining or delaying the procedure.
27. What does witnessing a signature mean? What does it not mean?
It means 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.
28. When must a patient complete a release of medical information form?
For purposes that are not part of medical treatment, payment, and health care operations (example: moving and having records forwarded to a new physician).
29. When does a release of medical information form not have to be completed?
For medical treatment, payment, and health care operations.
30. What is the difference between a PPR and an EMR?
A PPR is a paper-based patient record; an EMR is an electronic medical record.
31. What functions are performed by an EMR software program?
Creation, storage, organization, editing, and retrieval of a medical record on a computer.
32. What are the advantages of the electronic medical record?
EMRs can be retrieved quickly, do not need to be filed, reduced paper costs, time saved in not having to look for lost charts, easier to enter data into the record, ability to generate customized patient education instructions/handouts, to generate prescriptions, ready access to the patient record, and more than one person can view the chart at the same time.
33. How are paper documents entered into a patient’s electronic medical record?
By scanning them in.
34. What procedures typically are performed by a medical assistant using an EMR?
Access the daily schedule, select a patient, enter the time the patient checks in, enter the examination room number, enter the patient’s chief complaint, enter or review the patient’s history, enter or review patient allergies, enter or review the patient’s current medications, enter vital signs, enter height and weight measurements, enter results of tests, and enter laboratory test results.
35. How are documents organized in a source-oriented medical record?
They are organized into sections based on the department, facility, or other source that generated the information.
36. What is reverse chronological order?
The most recent document is placed on top or in front of the others.
37. How are documents organized in a problem-oriented medical record (POR)?
They are organized by the patient’s health problems.
38. List and describe the four parts of a POR.
Database: A collection of subjective and objective data used to compile a patient list.
Problem list: A list of patient conditions that require observation, diagnosis, management, or patient education.
Plan: A plan of action for further evaluation and treatment of each problem.
Progress notes: The follow-up for each problem in SOAP format.
39. List and describe the format used to organize progress notes in a POR.
Subjective data: Data obtained from the patient.
Objective data: Data obtained by observation, physical examination, laboratory, and diagnostic tests.
Assessment: Physician’s interpretation of the current condition based on an analysis of the subjective and objective data.
Plan: Proposed treatment for the patient.
40. How can a health history be entered into the EMR?
Patient completes a health history form and the MA scans it into the computer; the MA enters the information directly into the computer while asking the patient questions; the patient completes a computer-generated questionnaire.
41. What are the seven parts of the health history?
Identification data, chief complaint, present illness, past history, family history, social history, and review of systems.
42. What is a chief complaint?
The symptom that is causing the patient the most trouble.
43. What guidelines should be followed in recording the chief complaint?
An open-ended question should be used to elicit the chief complaint.
The chief complaint should be limited to one or two symptoms and should refer to a specific rather than a vague symptom.
The chief complaint should be recorded concisely and briefly.
The duration of the symptoms should be included in the chief complaint.
Names of diseases or diagnostic terms should be avoided in recording the chief complaint.
44. What is the current illness, and how is this information obtained?
A full and detailed description of the patient’s current illness from the time of its onset. It is obtained through a series of questions.
45. List five examples of information included in the past medical history.
Major illness, childhood diseases, unusual infections, accidents and injuries, hospitalizations and operations, previous medical tests, immunizations, allergies, and current medications.
46. List three examples of familial diseases.
Hypertension, heart disease, allergies, and diabetes mellitus.
47. Explain the importance of the social history.
The patient’s lifestyle may have an impact on the condition of that individual and influence the course of treatment chosen by the physician.
48. What is the purpose of the review of systems (ROS)?
To assist in identifying symptoms that might otherwise remain undetected.
49. List the guidelines that should be followed to ensure accurate and concise charting.
Check the name on the chart before making an entry.
Use black ink to make entries.
Write in legible handwriting.
Chart information accurately, using clear and concise phrases.
Chart immediately after performing a procedure.
Each charting entry should be signed by the person making it.
Never erase or obliterate an entry.
50. List three examples of subjective symptoms.
Pain, pruritus, vertigo, and nausea.
51. List three examples of objective symptoms.
Rash, coughing, and cyanosis.
52. What is the difference between a productive and a nonproductive cough?
With a productive cough, a discharge is produced. With a nonproductive cough, no discharge is present.
53. Why should the following be charted in the patient’s medical record?
a. Procedures performed on the patient To document that the procedure was performed.
b. Specimens collected from the patient To let the physician know that the specimen was collected and sent to the laboratory when test results are not back yet.
c. Laboratory tests ordered for the patient If the patient does not undergo the test, documented proof exists that the test was ordered.
d. Instructions given to the patient regarding medical care To document instructions given to the patient in the event that he or she fails to follow the instructions and causes further harm or damage to a body part.
Critical Thinking Activities
A. Medication Administration Record
Refer to the medication administration record (see Fig. 1-2) in your textbook, and answer the following questions.
1. Does Kristen Antle have any allergies? No.
2. How much Rocephin was administered to Kristen? 500 mg.
3. What was the route of administration of the Rocephin injection, and where was it administered? Intramuscular in the right dorsogluteal.
4. What is the name of the company that manufactures Rocephin? Roche.
B. Consultation Report
Refer to the consultation report (see Fig. 1-3) in your textbook, and identify the following information using the corresponding letter (A, B, C, or D).
1. Documentation that the consultant reviewed the patient’s health history
2. Documentation that the consultant examined the patient
3. A report of the consultants’ impressions
4. A report of the consultants’ recommendations
Refer to Figure 1-3.
C. Radiology Report
Refer to the radiology report (see Fig. 1-5) in your textbook, and answer the following questions.
1. What type of radiological examination was performed on Rose Baker? PA of the chest and abdomen.
2. Were the lungs clear? Yes.
3. Were any abnormal masses noted in the abdomen? No.
D. Diagnostic Imaging Report
Refer to the diagnostic imaging report (see Fig. 1-6) in your textbook, and answer the following questions.
1. What type of diagnostic imaging procedure was performed on Vera Ruth? CT of the lumbar spine.
2. What vertebrae of the spine were scanned? L3 through S1.
3. What problem may affect L4-5? Annular disk bulge or protrusion on the left.
4. What additional tests might be scheduled for Vera Ruth? Computed tomography of the lumbar spine.
E. Discharge Summary Report
Refer to the discharge summary report (see Fig. 1-10) in your textbook, and answer the following questions.
1. How long was Susan Brennan hospitalized? Three days from June 14 to June 16.
2. What was her hemoglobin level at admission? 10.8.
3. What was the reason for the hospitalization? Pelvic inflammatory disease; rule out ectopic pregnancy.
4. Was Susan pregnant? No.
5. What was her discharge diagnosis? Pelvic inflammatory disease.
F. Release of Medical Information
Refer to the release of medical information form (see Fig. 1-14) in your textbook, and answer the following questions.
1. What medical information is protected by law and cannot be released unless specifically authorized by the patient? Drug abuse diagnosis and treatment, alcoholism diagnosis and treatment, mental health diagnosis and treatment, and sexually transmitted disease.
2. List reasons why a patient may authorize the release of his or her medical information. Taking records to another physician, moving, legal purposes, insurance purposes, and workers’ compensation.