Questions and Answers
What is the term for 'patient complains of dizziness'?
a symptom
What is considered a condition that presents suddenly and is usually severe but of brief duration?
acute condition
What is data documentation in the patient's own words about why he or she presents to the office called?
subjective
Congestive heart failure and asthma are examples of what?
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What does the diagnosis 'type 1 diabetes' represent?
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Genetic disease risk is covered under which part of history?
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What documentation is necessary for an immunization?
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Weight and height are considered what?
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Smoking status of the patient would be discussed under which history type?
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What is the term for 'dizziness is on and off during the day'?
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What does 'blood pressure is 120/80 mm/hg' represent?
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An evaluation and management service provided online is known as what?
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What is 'MRI of the brain' an example of?
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What is the reason for the patient to seek care from the providers called?
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Vital signs, anthropometric data, imaging studies, and laboratory tests are examples of _________ information.
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What is the term for 'patient complains of urinary frequency'?
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An allergy to latex would be classified under what category?
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In SimChart for the medical office, the clinical record you land on after creating an encounter is?
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What is the term for 'patient has URI over the past 5 days'?
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What is the technology that converts speech into text called?
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Is it a guideline for e-visits that they may be offered to new and established patients?
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What starts the clinical documentation of a patient visit in SimChart for the medical office?
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What does documentation do in terms of medical care?
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T or F? It is common practice to mail a new patient the health and history from prior to his or her first visit.
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T or F? The administration and results of a patient's peak flow meter would be documented in Out-of Office order entry.
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T or F? When documenting a vaccination, route refers to the muscle that is used for an intramuscular injection.
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T or F? SimChart for the medical office allows the documenter to designate whether the medication is active or discontinued.
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T or F? The body mass index must be manually calculated in the vital signs record.
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T or F? The vaccine authorization is used to document any specific contraindication to having an immunization, for example, a high fever.
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T or F? ROS means 'review of symptoms'.
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T or F? The immunization record must include the lot number of the vaccine.
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T or F? When a note is signed electronically, the provider is representing that everything within the note is correct.
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T or F? The allergies record requires the user to select an allergen from a drop down box in SimChart for the medical office.
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T or F? Documentation of an active medication list is part of the core objectives.
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Study Notes
Patient Symptoms and Conditions
- Dizziness reported by a patient is classified as a symptom.
- An acute condition is characterized by sudden onset, severity, and brief duration.
- Congestive heart failure and asthma are classified as acute conditions.
- The term CC (Chief Complaint) refers to the reason a patient seeks care, such as urinary frequency.
Documentation Types
- Data documentation in the patient's own words is categorized as subjective information.
- Objective information includes measurable data like blood pressure readings (e.g., 120/80 mm/hg).
- Vital signs, anthropometric data, imaging studies, and laboratory tests are also examples of objective data.
- The evaluation and management service provided through secure online systems is known as an e-visit or online consultation.
Clinical History and Assessments
- The family history section includes genetic disease risks.
- Social history encompasses information such as smoking status.
- Chronology describes the timing of symptoms, like "dizziness is on and off during the day."
- Assessment involves evaluating a condition, e.g., diagnosing type 1 diabetes.
Immunization and Health Records
- Immunization documentation must include the name, date given, administrator, and injection location.
- An allergy to latex is classified under environmental history.
- Anthropometric measurements refer to height and weight.
- Duration of symptoms is important, such as stating a patient has had a URI for the past 5 days.
Health Technology and Documentation Practices
- Speech recognition software converts spoken language into text for efficient documentation.
- Clinical documentation improves diagnosis and treatment efficiency and enhances patient safety.
- Electronic health records may start with an encounter to begin documentation in SimChart for the medical office.
- It is common to send health history to new patients before their initial visit.
True/False Statements for Quick Reference
- E-visits may be offered to new and established patients: False.
- Documentation must include the lot number of the vaccine: True.
- Vaccination route refers to the muscle used for intramuscular injections: False.
- When electronically signing a note, the provider confirms the accuracy of its content: True.
- Documentation of an active medication list is part of the core objectives: True.
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Description
Test your knowledge with these flashcards covering essential concepts from Chapter 5 of Electronic Health Records (EHR). Topics include symptoms, conditions, and patient documentation. Perfect for healthcare students and professionals looking to reinforce their understanding.
