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Student Clinic Orientation > Final > Flashcards

Final Flashcards

1
Q

A patient has neck, shoulder and knee pain. What OATs are needed?

A

SF-36, QVAS and NDI

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2
Q

After doing a history, you need to get your advising Doc to review and sign off on it before you may start the exam. True or false

A

True

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3
Q

What OATS are needed for neck pain & dizziness?

A

SF-36, QVAS, NDI and DHI

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4
Q

What OATS are needed for low back pain and headaches?

A

SF-36, QVAS, RODI & HDI

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5
Q

When do you use a regional exam?

A

When the patient isn’t responding to care, presents with a new complaint or has extremity pain.

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6
Q

What OATS are needed for a patient with no chief complaint?

A

SF-36

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7
Q

You need DDX, rationale, OATS completed and a doctor’s signature before you can start an exam. True or false

A

True

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8
Q

What does PGIQ stand for?

A

Patient General Information Questionnaire

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9
Q

What does OATS stand for?

A

Outcome assessment tool

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10
Q

When a positive is elicited during an ortho test, what do you need to document?

A

Site, severity and quality of pain

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11
Q

If there’s discrepancy in blood pressure when done bilaterally, what do you do?

A

Make sure you’re using the right sized cuff, retake, and then tell your advising doctor

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12
Q

After an exam or CMR, you need informed consent (true or false)

A

True

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13
Q

What does HHW stand for?

A

Health History Worksheet

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14
Q

What does HIPAA stand for?

A

Health Insurance Portability and Accountability Act

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15
Q

Interns can have open discussion about one another’s patients in the student prep room. True or false.

A

False

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16
Q

CMR?

A
  1. Appointment at records desk
  2. Signed CMR credit form
  3. CMR
  4. Intern case log on N drive
  5. CMR IQA (Intern Qualitative Assessment)
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17
Q

Written permission from a patient allowing the practice to use that patient’s PHI for TPO purposes is what?

A

Consent

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18
Q

The unauthorized acquisition, access, uses or disclosure of PHI which compromises the security or privacy of such information is considered a what?

A

Breach

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19
Q

What is normal specific gravity?

A

Between 1.003 and 1.035

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20
Q

A goal of the US government based on HITECH Act is a certified electronic health record of every US citizen by 2014. True or false?

A

True

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21
Q

The HIPAA privacy rule does not allow a healthcare provider to mail out appointment reminders. True or false

A

False

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22
Q

What is the purpose of the patient history?

A

To collect information, develop a relationship with the patient and educate/motivate the patient

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23
Q

Which of the following is the appropriate method to identify a saved CMR?

A

filenumber.cmr

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24
Q

An intended result of HIPAA was to what?

A

Accountability, privacy, electronic records, simplify billing and implement a big brother nation (really?)

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25
The means by which privacy and confidentiality are ensured?
Security
26
How many systems do you need to cover during the review of systems?
10
27
A 'no answer' score on DH is?
0
28
Heart rate, blood pressure and respiration should be done bilaterally. True or false.
False.
29
If your chief complaint is LBP, you still have to do cervical ROM and ortho tests. True or false
True
30
What determines who should have access and patient's rights to confidentiality and inappropriate access?
Privacy
31
Written permission granted by patient or the patient's guardian to use or disclose PHI for purposes other than TPO is what?
Authorization. NOT consent!
32
To de-identify a patient record requires the removal of 18 different bits of information. True or false?
True
33
Any release, transfer, provision of access to or divulging in any other manner of protected health information outside the entity holding the information is what?
Disclosure
34
Who is the Life University Compliance Officer responsible for all things HIPAA?
Dr. Tim Guest
35
Life University is designated as a?
Hybrid entity
36
What ist he best doctor/patient orientation for interaction during the history?
Facing one another with no furniture between
37
What ist he purpose of an open-ended question?
Leaves discretion to the patient about the extent of the answer
38
If a patient is in an auto accident and undergoing litigation, they can stay under care at CCHOP. True or false.
False!
39
What does SLIDE stand for and what is it used for?
Single Line Initial Date new Entry. It's used for correcting mistakes
40
What determines how the records should be protected from inappropriate access?
Confidentiality
41
A subset of health information including demographics collected from an individual is what?
Individually Identifiable Health Information
42
What sheet is used for the chief complaint?
HHW (health history worksheet)
43
Of the following, what patient information are you allowed to store on personal storage devices?
Name and basic contact information such as phone number or email
44
Individually identifiable health information created, maintained or in the possession of the practice relating to the health records and management of a patient is what?
Protected health information
45
Under the HITECH changes to HIPAA an employee is not held to the same level of responsibility for PHI breaches as the employer. True or false
False
46
Patient present with neck pain. Give 2 related symptoms.
Local pain, radiating pain, tingling, numbness, etc.
47
Give an example of an ADL
Brushing teeth, getting dressed or showering
48
Anyone who performs or assists in certain functions, activities or services on behalf of the covered entity involving the use or disclosure of individually identifiable health information
Business associate
49
What's in the project?
History, exam and CMR
50
HDI deals with physical and emotional headaches... (unsure of question)
True
51
What needs to be done to correct an entry?
SLIDE (single line date new entry)
52
What ink is allowed in files?
Black or blue
53
Patient is not in for 70 days. What is required at next visit?
Re-physical
54
What is required before an intern can enter clinic?
HIPAA compliance and CPR
55
How often must the intern go to clinic?
Minimum of 3x each week to sign in
56
When is RODI used?
Back Pain
57
The correct name and password for Opal Rad is
aaaa aaaaaaaa or aaa aaaaaaaa
58
To draw a line on the image you click on the arrow in the tool bar...
False, that will draw an arrow
59
After acquiring the x-ray study, the intern has how many business days to make their presentation?
2 days (or loose the credit)
60
To qualify for toggle films, you must have supine leg length deficiency of 3/16 inch or more and dual probe thermographic scan revealing pattern and thermal asymmetry in the atlas fossa. True or false?
True
61
How do you change the contrast of an image?
Right mouse button, while in zoom mode & magnifying lens mode
62
How many x-rays are required for 9th quarter?
None
63
Postural asymmetry must be noted to qualify for full spine films?
True
64
X-ray listings must be documented for all subluxations found on physical exam
False
65
Dots required for ilium analysis
16
66
Where does the printed CMR summary go?
Left side of the file
67
The first step in initiating a new patient process is to have the intern complete the Health Intake Request Form (HIR)?
True
68
A "start time" is required before beginning your new patient consultation. True or false
True
69
You are required to determine a differential/initial dx based upon patient history and PRIOR to conducting the chiropractic and screening exam
True
70
What do you need to add under review of systems in EHR?
Emergency contact, immunological/psychological/EENT, and Family history (grandparents)
71
There should be blanks on the green sheets.
FALSE. Draw an arrow through the rest of the sheet if you have no tertiary complaints.
72
The history of your new patients secondary complaint is fully documented on which form?
Additional Health History worksheet
73
The initial or differential diagnosis should be determined prior to conducting a physical exam for new patients
True
74
LU clinics do not accept insurance including medicare and medicaid
True
75
SF36...
Should be filled out by EVERY patient over the age of 14 years old regardless of complaint at physical and re-physical.
76
RODI...
Strictly for LBP. 10 questions with 6 option choices
77
BPI...
Back Pain disability index
78
NDI
Neck Disability index reserved for neck pain
79
HDI
headache disability index
80
QBOX
Quadruple visual analog scale, used for any acute pain.
81
On consultation your patient states that she has experienced low back pain in the past but has been asymptomatic for 6 weeks. What's her chief complaint?
Low back pain. Within 90 days is considered current
82
All current musculoskeletal complaints are to be documented on the HHW and AHHW's using the OPQRST format
True
83
At 1st reassessment since initial exam your 19-year-old patient's chief complaint of severe, acute headaches has resolved. Which OATS must be completed?
SF-36, QVAS and HDI
84
A preferred source for creating ADLs would be?
OATs
85
The first line of the patient care plan should be updated at beginning of every patient encounter?
True
86
To complete the CMR process for credit, what is required of you?
Completed note, CMR credit form, intern case log, individual quality assessment
87
Within 48 hours of taking x-rays, (2 business days) the intern must complete the Intern of Radiology Report and review films with the LU radiologist
True
88
ICD-9 codes and PC codes can be used interchangeably for documentation purposes
False
89
On an initial exam the patient scored a 2% on the HDI. Is another required at the next assessment?
Yes
90
"Post findings" and specific date of next visit must be noted in to the assessment speed note
False
91
You adjustment findings such as leg checks, static and mopal findings are documented in the objective speed note?
True
92
On each routine adjustment visit and IQA (individual quality assessment) is to be opened by the intern and completed by the supervising clinician, even if no adjustment is needed
True
93
An explanation is required for any positive ortho, neuro, or ROM test greater than 5 degrees above/below normal?
True
94
DHI stands for what?
Dizziness handicap inventory

Student Clinic Orientation (2 decks)

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