MOPS

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Author:
shaketarenae
ID:
45842
Filename:
MOPS
Updated:
2010-10-29 00:48:28
Tags:
Pts Record Unit Test Review
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Description:
Patient Record Unit Test Review
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  1. CORRELATION
    To show a mutual relationship
  2. DIAGNOSIS
    The determination of the nature\ cause of a disease.
  3. DISCERNIBLE
    To see or understand a difference between two things.
  4. INTEGRAL
    Being an indispensable part of a whole.
  5. MEDICAL RECORD
    A complete set of information put down in writing to authenticate evidence of facts and events.
  6. MEDICAL REPORT
    A permanent legal document formally stating the results of an examination.
  7. OBJECTIVE (info)
    Preceptible to the observer\external senses (i.e. Dr's conclusions).
  8. OBSERVATION
    An inference from what has been seen or heard.
  9. PROFICIENCY
    Competency as a result of training & experience.
  10. PROGNOSIS
    The forecast of the outcome of a disease\injury.
  11. PROGRESS NOTES
    Records of patient visits, phone calls, progress & treatment that are inserted into the pts. chart.
  12. SIGN
    Any objective evidence of disease discoverable by a Dr. on examination of a patient.
  13. SUBJECTIVE
    Findings perceptible only by the affected person.
  14. SYMPTOM
    Any perceptible change in the body or its functions (Indicating disease or illness).
  15. Earache x 3 days
    Subjective
  16. Sore throat
    Subjective
  17. Pulse 88bpm
    Objective
  18. Tonsillectomy
    Subjective & Objective
  19. Mother died at age 68
    Subjective
  20. Appendectomy at age 12
    Subjective
  21. Arrhythmia
    Objective
  22. Patient has Blue Cross/Blue Shield insurance
    Subjective
  23. Address Change
    Subjective
  24. Mastectomy
    Objective & Subjective
  25. What is the difference between a medical report and a medical record?
    • Report is a single document.
    • Record is a complete set of information.
  26. The determination of a disease is known as the
    Diagnosis
  27. The study of the causes of origin of a disease is known as
    Etiology
  28. Forcasting the outcome of the diagnosis
    Prognosis
  29. A sign is_____________ information.
    Objective
  30. A symptom is _____________ information.
    Subjective
  31. SOAP is an acronym for
    Subjective, Objective, Assessment, Plan
  32. Write out the proper procedure for correcting an error in a patient's chart.
    Draw a single line through the error, write word error, date and initial.
  33. List three benefits of shingling.
    • Saves space
    • Prevents loss of records
    • Allows for the most recent report to be readily available (test results, x-ray reports, urinalysis reports)
  34. The SOAP approach of writing progress notes is known as the _____ method of record keeping.
    traditional
  35. Whether you shingle or not, how should reports be placed in a patient's chart.
    The most recent report is always placed on top.
  36. List three things medical records are used for:
    • Patient education
    • Research
    • Evaluating quality of treatment
  37. What should be known about the patient record.
    The patient record is a legal document, and always kept confidential.
  38. Congenital means ___________. List examples.
    • at birth
    • ex. down syndrome, cleft lip
  39. Are congenital defects considered subjective or objective?
    both subjective and objective
  40. What should be known about the patient's chart upon completion of treatment?
    Know that a physician should always chart the condition of a patient upon termination of treatment and this information is considered objective.
  41. What is a Pocket Call Record?
    A notebook which a physician carries to out of office visits.
  42. What should be done before any transcribed notes or laboratory reports are placed in a patient's medical record?
    The Physician must initial them.
  43. What does the acronym POMR stand for?
    Problem Oriented Medical Record
  44. Know the difference between percussion, inspection, palpation, and ausculatation.
    • Percussion: tap on the body
    • Inspection: observation
    • Palpation: feel with hands
    • Auscultation: listen to sounds
  45. How does the correction of a handwritten entry differ from that of a typewritten entry?
    • The corrrections are the same.
    • Draw a single line through the error, write word error, date and initial.
  46. Chills
    Subjective
  47. Amputation
    Objective & Subjective
  48. Pain with urination
    Subjective
  49. Abnormal lung sounds
    Objective
  50. Tubes in Ear
    Objective & Subjective
  51. Down Syndrome
    Objective & Subjective
  52. Occult blood in stool
    Objective
  53. Shortness of breath
    Objective & Subjective
  54. Nausea
    Subjective
  55. Runny nose
    Objective & Subjective
  56. Visible blood in stool
    Subjective
  57. Condition at time of termination of treatment
    Objective
  58. Diarrhea
    Subjective
  59. Hgb 12.5g/dL
    Objective
  60. Diabetic maternal grandmother
    Subjective

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