Medical Records & Documentation

Question 1

Define:

Medical Record

Answer 1

A comprehensive document that contains a patient’s medical history, diagnoses, treatments, and other health-related information.

The doctor reviewed the Medical Record to understand the patient’s previous treatments.

Question 2

Define:

Health Record

Answer 2

A collection of information about a person’s health, including medical history, treatments, and outcomes.

The nurse updated the Health Record after the patient’s last visit.

Question 3

Define:

Patient Chart

Answer 3

A systematic documentation of a patient’s medical history and clinical data, used by healthcare professionals for treatment planning.

The physician referred to the Patient Chart to assess the patient’s progress.

Question 4

Define:

Progress Notes

Answer 4

Notes made by healthcare providers that document a patient’s progress during treatment and any changes in their condition.

The Progress Notes indicated significant improvement in the patient’s recovery.

Question 5

Define:

Encounter Note

Answer 5

A record of a specific patient visit, detailing the reason for the visit, findings, and recommendations.

The Encounter Note summarized the patient’s symptoms and the doctor’s advice.

Question 6

Define:

Admission Note

Answer 6

A document created upon a patient’s admission to a healthcare facility that includes medical history and initial assessments.

The Admission Note provided essential background information for the attending physician.

Question 7

Define:

Discharge Summary

Answer 7

A report that summarizes a patient’s hospital stay, including diagnoses, treatments, and follow-up care recommendations.

The Discharge Summary outlined the patient’s care plan after leaving the hospital.

Question 8

Define:

H&P (History and Physical)

Answer 8

A comprehensive document that includes a patient’s medical history and the results of their physical examination.

The surgeon reviewed the H&P before proceeding with the operation.

Question 9

Define:

Flow Sheet

Answer 9

A tool used to document patient data over time, often in a graphical format, to monitor progress and treatment outcomes.

The nurse used a Flow Sheet to track the patient’s vital signs daily.

Question 10

Define:

Problem List

Answer 10

A comprehensive list of a patient’s current medical problems, often included in their medical record for reference.

The Problem List helped the healthcare team prioritize treatment plans.

Question 11

Define:

Treatment Plan

Answer 11

A detailed outline of the strategies and interventions designed to address a patient’s specific medical issues.

The doctor presented the Treatment Plan to the patient during the consultation.

Question 12

Define:

Care Plan

Answer 12

A document that outlines the specific actions to be taken to provide care to a patient, based on their needs and goals.

The Care Plan was adjusted to better meet the patient’s rehabilitation goals.

Question 13

Define:

Narrative Note

Answer 13

A descriptive account of a patient’s condition, treatment, and progress, written in a free-text format.

The physician wrote a Narrative Note to capture the details of the patient’s visit.

Question 14

Define:

Documentation Standards

Answer 14

The established guidelines for how medical records should be created, maintained, and stored to ensure accuracy and compliance.

The clinic adheres to strict Documentation Standards to maintain patient confidentiality.

Question 15

Define:

Audit Trail

Answer 15

A secure record that tracks changes made to a patient’s medical record, including who made the changes and when.

The Audit Trail revealed who accessed the patient’s sensitive information.

Question 16

Define:

Continuity of Care Document (CCD)

Answer 16

A standardized document that summarizes a patient’s care over time, facilitating communication among healthcare providers.

The Continuity of Care Document (CCD) was shared between the primary care physician and the specialist.

Question 17

Define:

Medical History

Answer 17

A comprehensive account of a patient’s past health issues, treatments, and family health history.

The physician gathered the Medical History to understand the patient’s background.

Question 18

Define:

Review of Systems (ROS)

Answer 18

A systematic approach to obtaining a patient’s medical history by reviewing each body system for symptoms.

During the exam, the doctor conducted a Review of Systems (ROS) to identify any underlying issues.

Question 19

Define:

Differential Diagnosis (DDx)

Answer 19

The process of distinguishing a disease or condition from others that present similar clinical features.

The doctor compiled a Differential Diagnosis (DDx) to determine the cause of the patient’s symptoms.

Question 20

Define:

Chief Complaint (CC)

Answer 20

The primary reason for a patient’s visit to a healthcare provider, typically stated in their own words.

The Chief Complaint (CC) was recorded as severe chest pain.

Question 21

Define:

SOAP Note

Answer 21

A structured method of documentation that includes Subjective, Objective, Assessment, and Plan components of patient care.

The clinician used a SOAP Note format to organize the patient’s visit information.

Question 22

Define:

Subjective

Answer 22

The portion of a medical note that includes the patient’s personal statements about their symptoms and experiences.

The Subjective section detailed the patient’s complaints and feelings about their condition.

Question 23

Define:

Objective

Answer 23

The part of a medical note that includes measurable or observable data collected during the examination.

The Objective findings showed elevated blood pressure readings.

Question 24

Define:

Assessment

Answer 24

The healthcare provider’s evaluation of the patient’s condition based on subjective and objective data.

The Assessment concluded that the patient was experiencing an exacerbation of asthma.

Question 25

# Define: Plan

Answer 25

The **proposed course of action to address the patient's condition**, including treatments and follow-up appointments. ## Footnote The *Plan* included medication adjustments and a follow-up visit in two weeks.

Question 26

# Define: HPI (History of Present Illness)

Answer 26

A **detailed account of the patient's current health issue**, including the timeline and nature of symptoms. ## Footnote The *HPI* revealed that the patient had been experiencing headaches for the past month.

Question 27

# Define: Vital Signs

Answer 27

**Measurements that provide essential information about a patient's basic bodily functions**, including heart rate, blood pressure, temperature, and respiratory rate. ## Footnote The nurse recorded the *Vital Signs* to assess the patient's health status.

Question 28

# Define: Physical Exam (PE)

Answer 28

A **systematic examination of a patient's body** to assess their health and detect any medical conditions. ## Footnote The doctor performed a *Physical Exam (PE)* to check for any abnormalities.

Question 29

# Define: Impression

Answer 29

The **clinician's initial interpretation** of the patient's condition based on the examination findings. ## Footnote The *Impression* suggested that the patient may have an upper respiratory infection.

Question 30

# Define: Follow-up

Answer 30

A **subsequent appointment or check-in** to monitor a patient's progress after treatment or intervention. ## Footnote The patient was scheduled for a *Follow-up* visit in one month.

Question 31

# Define: Intervention

Answer 31

An **action taken to improve a patient's health** or manage their condition, often part of a treatment plan. ## Footnote The *Intervention* included physical therapy to aid in the patient's recovery.

Question 32

# Define: Assessment Findings

Answer 32

The **results obtained from various evaluations** conducted during a patient's examination, used to inform diagnosis and treatment. ## Footnote The *Assessment Findings* indicated that the patient had a sprained ankle.

Question 33

# Define: Clinical Judgment

Answer 33

The **healthcare provider's ability** to assess and make decisions regarding a patient's care based on their knowledge and experience. ## Footnote The physician's *Clinical Judgment* led to the diagnosis of a rare condition.

Question 34

# Define: Referral

Answer 34

The **process of directing a patient to another healthcare provider** for specialized care or treatment. ## Footnote The doctor made a *Referral* to a cardiologist for further evaluation.

Question 35

# Define: BP (Blood Pressure)

Answer 35

The **force of blood against the walls of the arteries**, measured in millimeters of mercury (mmHg). ## Footnote The patient's *BP* was recorded as 120/80 mmHg during the examination.

Question 36

# Define: HR (Heart Rate)

Answer 36

The **number of times the heart beats per minute**, an important indicator of cardiovascular health. ## Footnote The patient's *HR* was elevated at 110 beats per minute due to anxiety.

Question 37

# Define: RR (Respiratory Rate)

Answer 37

The **number of breaths taken per minute**, used to assess a patient's respiratory function. ## Footnote The nurse noted that the patient's *RR* was 22 breaths per minute, indicating mild distress.

Question 38

# Define: O2 Sat (Oxygen Saturation)

Answer 38

The **percentage of hemoglobin in the blood** that is saturated with oxygen, usually measured with a pulse oximeter. ## Footnote The patient's *O2 Sat* was measured at 95%, indicating adequate oxygenation.

Question 39

# Define: WNL (Within Normal Limits)

Answer 39

A term used to indicate that a **patient's test results or physical examination findings fall within the established normal range**. ## Footnote The lab results were reported as *WNL*, suggesting no immediate concerns.

Question 40

# Define: PRN (As Needed)

Answer 40

A medical abbreviation indicating that a **medication or treatment should be administered only when necessary**. ## Footnote The patient was prescribed pain medication *PRN* for discomfort.

Question 41

# Define: NPO (Nothing by Mouth)

Answer 41

A medical instruction indicating that a **patient should not eat or drink anything for a specified period**. ## Footnote The patient was placed *NPO* before the scheduled surgery.

Question 42

# Define: PO (By Mouth)

Answer 42

A term used to indicate that a **medication or treatment should be administered orally**. ## Footnote The doctor prescribed the medication to be taken *PO* twice daily.

Question 43

# Define: IV (Intravenous)

Answer 43

A method of **delivering fluids, medications, or nutrients directly into a patient's bloodstream through a vein**. ## Footnote The patient received hydration via an *IV* during their hospital stay.

Question 44

# Define: IM (Intramuscular)

Answer 44

A route of medication administration where the **drug is injected directly into a muscle**. ## Footnote The vaccine was administered *IM* in the deltoid muscle.

Question 45

# Define: BID (Twice a Day)

Answer 45

A medical abbreviation indicating that a **medication should be taken two times per day**. ## Footnote The patient was instructed to take the antibiotic *BID* for seven days.

Question 46

# Define: TID (Three Times a Day)

Answer 46

A medical abbreviation indicating that a **medication should be taken three times per day**. ## Footnote The doctor prescribed the medication to be taken *TID* with meals.

Question 47

# Define: QID (Four Times a Day)

Answer 47

A medical abbreviation indicating that a **medication should be taken four times per day**. ## Footnote The patient was advised to take the medication *QID* for optimal effectiveness.

Question 48

# Define: STAT (Immediately)

Answer 48

A medical term used to indicate that **something needs to be done without delay**. ## Footnote The nurse was instructed to obtain the lab results *STAT* due to the patient's condition.

Question 49

# Define: Dx (Diagnosis)

Answer 49

The **identification of a disease or condition** based on the evaluation of a patient's symptoms and medical history. ## Footnote The *Dx* was confirmed after reviewing the test results.

Question 50

# Define: Tx (Treatment)

Answer 50

The **management and care provided to a patient** for the purpose of combating a disease or condition. ## Footnote The *Tx* plan included medication and physical therapy.

Question 51

# Define: Rx (Prescription)

Answer 51

A **written order from a healthcare provider** for a specific medication or treatment for a patient. ## Footnote The pharmacist filled the *Rx* for the patient's pain medication.

Question 52

# Define: Sx (Symptoms)

Answer 52

The **signs or indications of a disease** or condition as experienced by the patient. ## Footnote The patient reported several *Sx* including fatigue and shortness of breath.

Question 53

# Define: Fx (Fracture)

Answer 53

A **break in a bone** that can result from trauma, overuse, or certain medical conditions. ## Footnote The X-ray confirmed a *Fx* of the patient's right wrist.

Question 54

# Define: Hx (History)

Answer 54

A **record of a patient's past medical issues, treatments, and family history** relevant to their current health. ## Footnote The physician reviewed the patient's *Hx* to identify potential risk factors.

Question 55

# Define: Informed Consent

Answer 55

A **process in which a patient is educated about the risks and benefits** of a procedure or treatment before agreeing to it. ## Footnote The patient signed the *Informed Consent* form prior to surgery.

Question 56

# Define: HIPAA (Health Insurance Portability and Accountability Act)

Answer 56

A **U.S. law that provides privacy standards** to protect patients' medical records and other health information. ## Footnote The clinic ensures compliance with *HIPAA* regulations to safeguard patient data.

Question 57

# Define: Confidentiality

Answer 57

The **ethical principle of keeping patient information private** and secure from unauthorized access. ## Footnote The healthcare provider emphasized the importance of *Confidentiality* in handling patient records.

Question 58

# Define: Privacy Rule

Answer 58

A **component of HIPAA** that establishes national standards for the protection of individuals' medical records and personal health information. ## Footnote The *Privacy Rule* ensures that patients' health information is kept secure.

Question 59

# Define: Security Rule

Answer 59

A **HIPAA regulation** that sets standards for safeguarding electronic protected health information (ePHI). ## Footnote The *Security Rule* mandates that healthcare providers implement measures to protect ePHI.

Question 60

# Define: Protected Health Information (PHI)

Answer 60

Any individually **identifiable health information** that is transmitted or maintained in any form, as protected by HIPAA. ## Footnote The clinic must ensure the security of *Protected Health Information (PHI)* to comply with regulations.

Question 61

# Define: Authorization

Answer 61

A **patient's formal permission** for a healthcare provider to use or disclose their health information for specific purposes. ## Footnote The patient provided *Authorization* for the release of their medical records.

Question 62

# Define: Legal Liability

Answer 62

The **legal responsibility of healthcare providers to provide care** that meets accepted standards, and to be accountable for any harm caused. ## Footnote The physician was aware of the *Legal Liability* involved in performing the procedure.

Question 63

# Define: Compliance

Answer 63

The **process of adhering to laws, regulations, and guidelines** relevant to healthcare practices and patient care. ## Footnote The facility implemented new policies to ensure *Compliance* with federal regulations.

Question 64

# Define: Risk Management

Answer 64

The **identification, assessment, and prioritization of risks** followed by coordinated efforts to minimize, monitor, and control the probability of unfortunate events. ## Footnote The hospital's *Risk Management* team worked to prevent potential liabilities.

Question 65

# Define: Medical Malpractice

Answer 65

A **legal term** referring to **professional negligence** by a healthcare provider that results in harm to a patient. ## Footnote The patient filed a claim for *Medical Malpractice* after receiving improper treatment.

Question 66

# Define: Standard of Care

Answer 66

The **level of care and skill** that a reasonably competent healthcare provider would provide in similar circumstances. ## Footnote The court evaluated whether the physician met the *Standard of Care* in the treatment provided.

Question 67

# Define: Documentation Errors

Answer 67

**Mistakes or inaccuracies in medical records** that can lead to miscommunication and negatively impact patient care. ## Footnote The audit revealed several *Documentation Errors* that needed correction.

Question 68

# Define: Addendum

Answer 68

An additional **document added to a medical record** to provide more information or clarification after the original entry was made. ## Footnote The physician submitted an *Addendum* to clarify the patient's treatment plan.

Question 69

# Define: Amendment

Answer 69

A **formal change or correction made to a medical record** to rectify inaccuracies or update information. ## Footnote The patient's *Amendment* to their medical history was approved by the provider.

Question 70

# Define: E-signature

Answer 70

An **electronic signature that is used to sign documents** in a digital format, providing authenticity and integrity to electronic records. ## Footnote The provider used an *E-signature* to approve the patient's treatment plan.

Question 71

# Define: Electronic Health Record (EHR)

Answer 71

A **digital version of a patient's paper chart** that contains comprehensive health information and is shared among healthcare providers. ## Footnote The clinic transitioned to an *Electronic Health Record (EHR)* system for better patient management.

Question 72

# Define: Electronic Medical Record (EMR)

Answer 72

A **digital record of a patient's health information** that is created and maintained by one healthcare provider. ## Footnote The doctor accessed the *Electronic Medical Record (EMR)* to review the patient's treatment history.

Question 73

# Define: Interoperability

Answer 73

The ability of different healthcare information systems and software applications to **communicate and exchange data** effectively. ## Footnote *Interoperability* between systems allows for seamless patient data sharing among providers.

Question 74

# Define: Clinical Decision Support (CDS)

Answer 74

Tools and systems that provide healthcare providers with **knowledge and patient-specific information** to enhance decision-making. ## Footnote The *Clinical Decision Support (CDS)* system alerted the physician to potential medication interactions.

Question 75

# Define: Patient Portal

Answer 75

An **online platform** that allows patients to access their health information, communicate with healthcare providers, and manage appointments. ## Footnote The patient logged into the *Patient Portal* to view their lab results.

Question 76

# Define: Health Information Exchange (HIE)

Answer 76

The **electronic sharing of health information among different healthcare organizations** to improve the quality of care. ## Footnote The *Health Information Exchange (HIE)* facilitated the transfer of the patient's records to the new specialist.

Question 77

# Define: Data Entry

Answer 77

The **process of inputting data into a computer system or database**, often used for maintaining patient records. ## Footnote Accurate *Data Entry* is crucial for keeping patient records up to date.

Question 78

# Define: Charting Templates

Answer 78

**Predefined formats used for documenting patient information** in electronic health records to ensure consistency and efficiency. ## Footnote The nurse utilized *Charting Templates* to streamline the documentation process.

Question 79

# Define: Order Entry (CPOE - Computerized Provider Order Entry)

Answer 79

An **electronic system that allows healthcare providers to place orders** for medications, tests, and other services directly into a patient's record. ## Footnote The physician used *Order Entry (CPOE)* to prescribe medication efficiently.

Question 80

# Define: E-prescribing

Answer 80

The **electronic generation and transmission of prescriptions** from a healthcare provider to a pharmacy. ## Footnote The doctor opted for *E-prescribing* to improve prescription accuracy.

Question 81

# Define: Data Security

Answer 81

The **protection of digital information from unauthorized access, corruption, or theft**, especially in healthcare settings. ## Footnote The clinic implemented measures to enhance *Data Security* for patient records.

Question 82

# Define: Access Control

Answer 82

A **security measure that regulates who can view or use resources in a computing environment**, particularly sensitive patient information. ## Footnote Effective *Access Control* is essential to maintain patient confidentiality.

Question 83

# Define: Audit Log

Answer 83

A **record that tracks all actions taken on a system**, including access and modifications to sensitive information, ensuring accountability. ## Footnote The *Audit Log* revealed who accessed the patient's records and when.

Question 84

# Define: Encryption

Answer 84

A method of **converting information or data into a code** to prevent unauthorized access, commonly used for protecting patient data. ## Footnote The patient's information was secured through *Encryption* to comply with privacy regulations.

Question 85

# Define: User Authentication

Answer 85

The process of **verifying the identity of a user** before granting access to a system or resource, crucial for protecting sensitive information. ## Footnote *User Authentication* ensures that only authorized personnel can access patient records.