Podcast
Questions and Answers
Which of the following elements typically includes information about habits such as smoking and alcohol consumption?
Which of the following elements typically includes information about habits such as smoking and alcohol consumption?
What part of the record format is primarily used to document the patient’s narrative of their current symptoms?
What part of the record format is primarily used to document the patient’s narrative of their current symptoms?
In a medical record, where would you typically find the list of the patient's known drug reactions?
In a medical record, where would you typically find the list of the patient's known drug reactions?
Which section of a patient’s record includes their blood pressure, heart rate, and temperature?
Which section of a patient’s record includes their blood pressure, heart rate, and temperature?
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Where in the medical record would one typically document the patient’s surgical interventions?
Where in the medical record would one typically document the patient’s surgical interventions?
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Which of the following is typically included in a medical record?
Which of the following is typically included in a medical record?
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What type of history specifically outlines a patient's previous illnesses in a medical record?
What type of history specifically outlines a patient's previous illnesses in a medical record?
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Which of these is not a component typically recorded in a patient's medical record?
Which of these is not a component typically recorded in a patient's medical record?
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What information in the medical record provides insight into the patient’s living habits and potential exposures?
What information in the medical record provides insight into the patient’s living habits and potential exposures?
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Which component of the medical record helps in identifying inherited health patterns?
Which component of the medical record helps in identifying inherited health patterns?
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What is a key characteristic of Electronic Medical Records (EMRs)?
What is a key characteristic of Electronic Medical Records (EMRs)?
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How are handwritten medical records typically created?
How are handwritten medical records typically created?
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Which description best fits EMRs?
Which description best fits EMRs?
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What distinguishes handwritten records from EMRs?
What distinguishes handwritten records from EMRs?
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In what aspect are EMRs and handwritten records similar?
In what aspect are EMRs and handwritten records similar?
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What is the primary function of medical coding?
What is the primary function of medical coding?
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Which manuals might a medical coder use to assign codes?
Which manuals might a medical coder use to assign codes?
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What is the initial step in the medical coding process?
What is the initial step in the medical coding process?
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In which stage does the creation of the medical record occur?
In which stage does the creation of the medical record occur?
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In the medical coding process, what does the medical coder do after analyzing the patient's medical record?
In the medical coding process, what does the medical coder do after analyzing the patient's medical record?
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What additional medication was prescribed along with the short course of prednisone?
What additional medication was prescribed along with the short course of prednisone?
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Which of the following symptoms did the patient deny experiencing?
Which of the following symptoms did the patient deny experiencing?
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Which physical exam finding was noted in the patient's lung examination?
Which physical exam finding was noted in the patient's lung examination?
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How long has the patient experienced difficulty expectorating?
How long has the patient experienced difficulty expectorating?
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Which of the following is NOT part of the patient's medical history?
Which of the following is NOT part of the patient's medical history?
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What was the patient's oxygen saturation level during the physical exam?
What was the patient's oxygen saturation level during the physical exam?
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What is the primary purpose of the E-Tool?
What is the primary purpose of the E-Tool?
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How does a 'Record' differ from an 'Encounter'?
How does a 'Record' differ from an 'Encounter'?
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Which statement accurately describes an 'Encounter'?
Which statement accurately describes an 'Encounter'?
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In which scenario could a patient record possibly have empty pages?
In which scenario could a patient record possibly have empty pages?
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What does the review process of medical records typically entail in the context of E-Tool usage?
What does the review process of medical records typically entail in the context of E-Tool usage?
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Which of the following elements is critical in identifying a patient in a medical record?
Which of the following elements is critical in identifying a patient in a medical record?
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Which of these is a key difference between electronic tools (E-tools) and traditional medical records?
Which of these is a key difference between electronic tools (E-tools) and traditional medical records?
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What is a significant advantage of face-to-face encounters in medical assessments?
What is a significant advantage of face-to-face encounters in medical assessments?
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Which of the following is not typically considered an element of a medical record?
Which of the following is not typically considered an element of a medical record?
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Why is the provider's signature an essential concept in medical records?
Why is the provider's signature an essential concept in medical records?
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What observation about the left ear is documented?
What observation about the left ear is documented?
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What does 'Px patent' signify in the document?
What does 'Px patent' signify in the document?
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Which term indicates a specific ear condition in the text?
Which term indicates a specific ear condition in the text?
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Which acronym or term in the document is not clearly defined and might need further clarification?
Which acronym or term in the document is not clearly defined and might need further clarification?
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What phrase indicates a normal physical examination of the cardiovascular system?
What phrase indicates a normal physical examination of the cardiovascular system?
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Which medication was added to the patient's treatment plan during the fourth encounter?
Which medication was added to the patient's treatment plan during the fourth encounter?
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What symptom did the patient NOT report during the subjective examination?
What symptom did the patient NOT report during the subjective examination?
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During the objective examination, which abnormal respiratory finding was observed?
During the objective examination, which abnormal respiratory finding was observed?
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What was the patient's oxygen saturation on room air during the physical examination?
What was the patient's oxygen saturation on room air during the physical examination?
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Which historical condition is listed in the patient's assessment?
Which historical condition is listed in the patient's assessment?
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What type of follow-up was planned for the patient?
What type of follow-up was planned for the patient?
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What is the patient's current smoking status?
What is the patient's current smoking status?
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Which diagnostic imaging was performed to check for disease recurrence?
Which diagnostic imaging was performed to check for disease recurrence?
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What type of follow-up is recommended for the patient?
What type of follow-up is recommended for the patient?
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How is the patient's physical condition described regarding lung examination?
How is the patient's physical condition described regarding lung examination?
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What treatment did the patient undergo after resection of the lung cancer?
What treatment did the patient undergo after resection of the lung cancer?
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Which of the following symptoms is NOT mentioned as absent in the patient's health report?
Which of the following symptoms is NOT mentioned as absent in the patient's health report?
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Study Notes
Medical Record
- A medical record is a document that explicitly describes a patient's current clinical picture.
- It includes current active diagnosis, past medical histories, social histories, surgical histories, family histories, physical exam, lab orders & values, medications, and radiology.
Elements of Record
- Patient demographic details
- CC - Chief Complaint
- HPI - History of Present Illness
- PMH - Past Medical History
- Surgical History
- Social History
- Family History
- ROS - Review of System
Other Elements
- Problem list/Active problem list/chronic problem list
- Medication list
- Allergy
- Risk Factors
- Vital Signs
- Physical Examination
- Assessment/Impression
- Plan/Refer
Types of Medical Record
- EMR (Electronic Medical Record)
- Handwritten records
EMR
- Electronic medical records (EMRs) are digital versions of the paper charts which include all the health information of the patient.
- EMR is a software where the coders enter the codes after reviewing the medical records.
Handwritten Records
- Handwritten records are written documents of patient information, health history, physical examination, and treatment plans instead of typing.
Medical Coding
- Medical coding is the transformation of healthcare diagnosis, procedures, medical services, and equipment into universal medical alphanumeric codes.
- Stages of medical coding:
- Patient meets physician
- Physician creates a medical record
- Medical coder analyzes the medical record
- Medical coder assigns codes using specified manuals
E-Tool
- E-Tool is a software where the coders enter the codes after reviewing the medical records.
Record vs Encounter
- Encounter: Patients each visit to the hospital or clinic regarding health issues.
- Record: A record may have either one visit or more than one number of visits. Some records may even have empty pages.
Examples of Handwritten Records
- Written document of patient details, including patient DOB, vital signs, physical examination, and treatment plans.
Examples of EMR Records
- Electronic version of patient's medical information, including history, physical examination, impression, and plan.
Provider Information
- Provider type: IP, OP, P
- Codes: 110 - Essential Hypertension
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Description
This quiz covers the essential components of a medical record, including patient demographics, chief complaint, medical history, and more. Test your knowledge of medical documentation and patient assessment.
