Patient Care/Administrative

Question 1

Medical records

Answer 1

A written account of a persons conditions and response to treatment and care, along with a patients medical history

Question 2

Reporting

Answer 2

The oral (spoken) account of patient related matters.

Question 3

Recording

Answer 3

The written or electronically recorded account of patient related matters.

Question 4

EMRS (Electronic medical records)

Answer 4

Digital collection of health related info that can be shared across different health care settings.

Question 5

POMR (Problem oriented medical record)

Answer 5

This type of record assigns a number to each problem, and the number is referenced when the patient arrives to receive care.

Question 6

SOMR (source oriented medical record)

Answer 6

Tracks down recording to a supplier or source, which can be an individual or department.

Question 7

Flow charts

Answer 7

Visual tools that help track certain info like an infant/child’s growth.

Question 8

Progress charts

Answer 8

Notes made during a patient visit to document their progress in treatment

Question 9

SOAP NOTES

Answer 9

A way to document subjective, objective, assessment, and planning aspects of a patients evaluation or treatment.

Question 10

Subjective data

Answer 10

What the patient, family members or other medical personnel describe.

Question 11

Objective data

Answer 11

Info that can be observed or results of objective tests such as lab results.

Question 12

Assessment

Answer 12

Pt’s clinical judgement, based on the evaluation or on the patient response to a current treatment sessions

Question 13

Plan

Answer 13

The pt’s treatment plan based on the evaluation for on the patients response to a current treatment session.

Question 14

Entry corrections

Answer 14

Draw a single line through the wrong info, date and initial the correction. Enter the corrected statement. Use black or blue ink.

Question 15

Vital signs

Answer 15

Measurement of a persons body temperature, heart rate, respiration rate, and blood pressure.
Vital signs can be used to establish a treatment and response to treatment.

Question 16

Pulse

Answer 16

Palpable wave of blood produced in the walls of arteries with each heartbeat or contraction.

Question 17

Hypertension

Answer 17

Abnormally HIGH bp.

Question 18

Hypotension

Answer 18

Abnormally LOW bp.

Question 19

Bradycardia

Answer 19

Slow heartbeat

Question 20

Tachycardia

Answer 20

Abnormally fast heart rate

Question 21

Stethoscope

Answer 21

An instrument used to convey sounds produced in the body or a person to the ears of the examiner. 

Question 22

Pulse oximeter

Answer 22

A medical device that measures levels of blood oxygen saturation, monitors pulse rate, and calculates heart rate.

Question 23

Blood pressure

Answer 23

The force of the blood against the walls of the arteries

Question 24

Systolic

Answer 24

The first beat heard. This is when the greatest amount of pressure is exerted on the walls of the arteries during a heartbeat.

Question 25

Diastolic

Answer 25

The last beat heard.. Which the least amount of pressure is exerted on the walls of the arteries during the heartbeat indicating the resting phase of the heartbeat. 

Question 26

Heart rate

Answer 26

Reflects number of times the heart beats each minute and is recorded as BPM ( beats per minute)

Question 27

Normal resting heart rates

Answer 27

Adult - 60-100 bpm
Newborn 100-160 bpm
Athletes 40-60 bpm

Question 28

Normal vital signs for adults under 65

Answer 28

Heart rate 60-100 bpm
Bp (blood pressure) 90/60 mm HG to 120/80 mm HG
Respiratory rate (RS) 12 to 20 breaths per minute
Body temp 97.5 to 99.1F

Question 29

Measuring body temp

Answer 29

Can be done orally or with an ear thermometer.

Question 30

How to take BP with a cuff and stethoscope

Answer 30

Have patient sit with feet flat on floor and arm resting at with the brachial artery at the level of the heart. Put correctly sized cuff onto patients arm above the elbow. Palpitate the brachial artery and secure the center of the cuff over the artery. Make sure the cuff is 1 inch above the artery. Locate and palpitate the brachial artery and inflate the cuff until the pulse is no longer felt. Note the number. Quickly deflate the cuff, allow arm to rest for one minute. Calculate the peak inflation level by adding 30 millimeters of mercury to the number where the pulse was no longer felt. Position the stethoscope over the brachial artery, hold stethoscope only with fingers, inflate cuff again, deflate by 2 to 4 mm per heartbeat. Listen for the systolic heartbeat and note the number. Then listen for the diastolic (silence) note number. After getting reading, continue to deflate by 10mm after all sounds have disappeared to avoid mistaken sound. Deflate quickly and remove cuff.

Question 31

How to take a Pulse rate

Answer 31

Make sure the wrist is resting upward on a lap or table. Place first 3 fingers on the wrist to find the pulse, slightly press to feel the pulse. Don’t use thumb as it has its own pulse. Count the beats for 1 whole minute. It can also be counted for only 30 seconds and times by 2 to get the reading.

Question 32

How to measure Respiration rate

Answer 32

Count the patients breath for 30 seconds and double the number.

Question 33

First aid

Answer 33

Medical attention that is usually administered immediately after the injury occurs at the location where it occurred. Often consists of a short term treatment and requires a little technology or training to administer.

Question 34

Wound care

Answer 34

Proper dressing to aid healing, as well as includes compression wrapping, casting, use of specialized ultrasound, negative pressure or electrical stimulation. Debridement (or surgical Debridement) is the removal of damaged , infected or dead tissue. PT’s use a sharp instrument or scalpel to cut away this tissue. Sometimes a high pressure irrigation devices, or topical ointment is also used to side the Debridement process.

Question 35

Insurance info

Answer 35

Insurance should be obtained prior to the visit to the pt facility. Types are aetna, Humana, united health group, and Kaiser permnanente