Wk1Assignment (4)
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MOA115 Medical Records and Insurance
Week 1 Assignment – Health Records Part 1 – Releasing Information and NPP
Directions:
Answer the following questions. Use your Kinn’s The Medical Assistant e-book as a resource. Type your answers below the question.
1.
Describe when a release form must be signed and indicate what information is included on the release form.
(Your answer) Valid release of information forms that are signed by the patient authorizes the provider
to to release the information to third party groups. Included in the release form is a
signature, date, and the information that they release
2.
Describe the Notice of Privacy Practices (NPP) – what is it? Why is it important for patients to receive the information? (Hint: Use the Index to find the NPP in the textbook.)
(Your answer)
Part 2– Study Guide Questions
Directions: Use the Kinn’s The Medical Assistant – Study Guide and Procedure Checklist Manual
for this assignment. You will also need to use the Kinn’s The Medical Assistant textbook as a resource.
Assigned Study Guide Questions:
Chapter 10 Health Records Skills and Concepts
A. Health Record Basics (Answer #1-3) 1.
Describe the following types of information found in a patient’s health record. Demographics:
(Your answer)
DOB, Age, Gender, Race, Ethnicity, Prefered Language, Contact Info, Religion, Education,
Occupation
Past health history:
Any illnesses that patient has previously had in medical record
MOA115 Medical Records and Insurance
Week 1 Assignment – Health Records (Your answer)
Family history:
(Your answer)
Any illnesses that family has had in the past, Causes of death, physical conditions
Social history:
(Your answer)
Smoking, drinking, tobacco use, employment, marital status, living. Anything that
includes a patient lifestyle
Chief complaint:
(Your answer)
Nature, location, frequency & duration of pain. When they first started noticing the
symptoms, any at home treatments that the patient could have used. If they have had
anything like this prior to this current visit.
Vital signs and anthropometric measurements:
(Your answer)
Temp, Pulse, Respiration, BP, Height and Weight
Diagnosis:
(Your answer)
Any test that the provider notes and runs for their diagnosis.
Progress notes:
(Your answer)
Follow up treatments, and the progress of the diagnoses
2.
Explain the importance of data backup:
(Your answer)
Power Outages, failure to download, human errors
3.
Define meaningful use
.
(Your answer)
System that provides saftey efficiency, helps reduce health disparities and improve care
MOA115 Medical Records and Insurance
Week 1 Assignment – Health Records coordination while engaging with patients & familys own care, privacy and security
B. Organization and Documentation in a Health Record (Answer #1-6) 1.
Identify the categories used for organizing information in a POR system.
(Your answer)
Database- chief complaint, history of present illness,paitent profile, review of systems,
physical exam and lab reports
Treatment- Management, additional workups and therapy
2.
Identify the method of organizing information in an SOR system. (Your answer)
They are catalogged according to their source, Provider, lab reports, radiology, hospital,
consloutions
3.
Identify equipment and supplies needed to create, maintain, and store health records. (Your answer)
Drawer files, shelf files, rolodexes, automated files, files folders and labels
4.
Describe the medical assistant’s responsibilities when documenting in the health record including skills and responsibilities
(Your answer)
Talking and logging medical history, taking and logging vital signs, also explain the
procedures and instruments that will be used and are going to be done to patients
Correct the following entries as would be done in the health record. Then rewrite the entries correctly. Handwritten corrections are acceptable on these exercises.
5.
The correct date of the appointment below was October 12, 20XX. 10-21-20XX 1330 Patient did not arrive for scheduled appointment. P. Smith, RMA
(Your answer)
10-21-20XX 1330 Patient did not arrive for scheduled appointment. P. Smith, RMA
10-12-20xx 1330 patient did not arrive for scheduled appoiment P. Smith. RMA
6.
The patient stated that the chest pain began 2 weeks ago.
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MOA115 Medical Records and Insurance
Week 1 Assignment – Health Records 1-31-20XX 10:00 am Patient complained of chest pain for the past 2 months. No pain noted in arms. No nausea. Desires ECG and blood work to check for heart problems. R. Smithee, CMA (AAM)
(Your answer)
01-31-20xx 10:00AM patient complained of chest pain for the past 2 weeks. No pain
noted in th arms, no nausea. Desires for ECG and blood work to check for heart
problems. R. Smithee. CMA (AAM
Document the following exercises.
7.
Eric Robertson canceled his surgical follow-up appointment today for the third time. Document this information.
(Your answer)
C. Indexing and Filing Rules (Answer #1-4) 1.
Describe the indexing rules for alphabetic filing. (Your answer)
By name is the oldest, easiest and most commonly used way. The correct name of
spelling must be known as the number of files increases move and space is needed for
each action and section of the alphabet
2.
Using alphabetic filing, place the names below in correct alphabetic order. Cassidy Kay Hale 1. ____Adams James Bentley
Candace Cassidy LeGrand 2. ____Adams Percival
MOA115 Medical Records and Insurance
Week 1 Assignment – Health Records Taylor Ann Jackson 3. ____Beall Ellen Starr
Anton Douglas Conn 4. ____Belk Riley
Mitchel Michael Gibson 5.
____Bruin Thomas
Lorienda Gaye Robison 6.
____Chapman Alishan
LaNelle Elva Crumley 7. ____Chapman Karry
Allison Gaile Yarbrough 8.
____Conn Anton Douglas
Sarah Kay Haile 9. ____Cumley La Nelle Elva
MOA115 Medical Records and Insurance
Week 1 Assignment – Health Records Marie Gracelia Stuart 10. ___Frazier Tamika
Karry Madge Chapmann 11. ___Gibson Mitchel
Randi Ann Perez 12. ___Gibson Mitchell
Cecelia Gayle Raglan 13. ___Haile Sarah Kay
Sarah Sue Ragland 14. ___Hale Cassidy Kay
Riley Americus Belk 15. ___Jackson Taylor
Starr Ellen Beall 16. ___Kizer Montana Skye
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MOA115 Medical Records and Insurance
Week 1 Assignment – Health Records Mitchell Thomas Gibson 17. ___LaRose Dakota
George Scott Turner 18. ___Legrand Candace
Winston Roger Murchison
19. ___Metxgel Robbie
Sara Suzelle Montgomery
20. ___Montgomery Sara
Tamika Noelle Frazier 21.
___Murchison WInston Roger
Alisa Jordan Williams 22. ___Perez Randi Ann
Alisha Dawn Chapman 23. ___Ragland Cecelia
MOA115 Medical Records and Insurance
Week 1 Assignment – Health Records Bentley James Adams 24.
___Ragland Sarah Sue
Montana Skye Kizer 25. ___Robinson Lorienda
Dakota Marie LaRose 26. ___Santos Carlos
Robbie Sue Metzger 27. ___Stuart Marie
Thomas Charles Bruin 28.
___Turner George Scott
Percival “Butch” Adams 29. ___Williams Alka
Carlos Perez Santos 30. ___Yarbrough Allison
Cassidy Kay Hale
1. ___Adams James Bentley___________________
Candace Cassidy LeGrand 2. __Adams Perciva_____________________
MOA115 Medical Records and Insurance
Week 1 Assignment – Health Records Taylor Ann Jackson 3. ____Beall Ellen Starr____________________
Anton Douglas Conn 4. __Belk Riley_____________________
Mitchel Michael Gibson 5. ___Bruin Thomas____________________
Lorienda Gaye Robison 6. ___Chapman Alishan____________________
LaNelle Elva Crumley 7. __Chapman Karry_____________________
Allison Gaile Yarbrough 8. ___Conn Anton Douglas____________________
Sarah Kay Haile 9. ___Cumley La Nelle Elva____________________
Marie Gracelia Stuart 10. ___Frazier Tamika____________________
Karry Madge Chapmann 11. __Gibson Mitche______________________
Randi Ann Perez 12. _____Gibson Mitchell___________________
Cecelia Gayle Raglan 13. ______Haile Sarah Kay__________________
Sarah Sue Ragland 14. ____Hale Cassidy Kay____________________
Riley Americus Belk 15. __Jackson Taylo_____________________
Starr Ellen Beall
16. ___Kizer Montana Skye____________________
Mitchell Thomas Gibson 17. __LaRose Dakota_____________________
George Scott Turner 18. _____Legrand Candace__________________
Winston Roger Murchison 19. ____Metxgel Robbie___________________
Sara Suzelle Montgomery 20. _Montgomery Sara______________________
Tamika Noelle Frazier 21._Murchison Winst Roge____________________
Alisa Jordan Williams 22. __Perez Randi Ann_____________________
Alisha Dawn Chapman 23. __Ragland Cecelia_____________________
Bentley James Adams 24. __Ragland Sarah Sue_____________________
Montana Skye Kizer 25. ___Robinson Lorienda____________________
Dakota Marie LaRose 26. ____Santos Carlos___________________
Robbie Sue Metzger 27. __Stuart Marie_____________________
Thomas Charles Bruin 28. __Turner George Scott_____________________
Percival “Butch” Adams 29. ____Williams Alka
______________________
Carlos Perez Santos
30. ___Yarbrough Allison____________________
3.
Why might color-coded files be more efficient than an alphabetic filing system?
(Your answer)
4.
Using terminal filing, place the numbers below in the correct order. 01-64-22
1. ____17-41-20_______________
72-55-20 2. ___44-41-20_______________
44-41-20 3. ___82-49-20_______________
17-41-20 4. __72-55-202________________
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MOA115 Medical Records and Insurance
Week 1 Assignment – Health Records 56-42-21 5. _56-42-21_________________
91-88-21 6. __91-88-21________________
15-24-22 7. ___08-94-21________________
82-49-20 8. ___15-24-22_______________
08-94-21
9. ____24-42-22______________
24-42-22
10. ____01-64-22_________________
D. Miscellaneous (Answer #1-2) 1.
Describe the difference between an EMR and a practice management system.
(Your answer)
2.
Describe a manual tickler file.
(Your answer)
It tickles the memories that something needs to be done or followed on particular data.
It is always chronological order, and has a daily calendar
Workplace Applications
(Answer #1-2) 1.
Dr. Martin wants to be sure the Walden-Martin Family Medical (WMFM) Clinic is meeting all of the requirements for meaningful use that are specified in the HITECH Act. He has asked Susan to put together a list of what WMFM Clinic should be doing to meet those requirements. What would be on Susan’s list?
(Your answer)
Start using HER Tech.
E-Precribing.
Submitting clinical reports, diagnoses code, surveys and other measures.
2.
Susan has been learning about the various EHR systems available. She has also been learning about the need to back up to protect the information stored in the EHR. Susan has asked the office manager at WMFC how the EHR is backed up at their facility. The office manager states that they currently use an external hard drive, but would like to look more closely at other options. She asks Susan to determine what other options are available. Write a brief description of each of the options below:
a.
External hard drive: (Your answer)
It is what connects to the computer, with different programs
MOA115 Medical Records and Insurance
Week 1 Assignment – Health Records b.
Full server backup: (Your answer)
A large capacity on a dedicated server, Capacity Computer
c.
Online backup system:
(Your answer)
Are easy to use because there is no external drive to worry about