practice management & EHR, chapter 6

past medical history (PMH)
patient’s history of medical problems, including chronic conditions, surgeries, and hospitalizations
progress notes
note documenting the care delivered to a patient, and the medical facts and clinical thinking relevant to diagnosis and treatment
patient flow
progression of patients from the time they enter the office for a visit until they exit the system by leaving the office after a visit
family history (FH)
detailed record of medical events among the patient’s relatives, including the ages, living status, and diseases of siblings, children, parents, and grandparents
history of present illness (HPI)
a description of the course of the present illness, including how and when the problem began, up to the present time
social history (SH)
information about the patient’s tobacco use, alcohol and drug use, sexual history, relationship status, and other significant social facts that may contribute to the care of the patient
review of systems (ROS)
an inventory of body systems in which the patient reports signs or symptoms he or she is currently having or has had in the past.
past, families, and social history (PFSH)
a commonly used abbreviation for past medical, family, and social history
T/F
Patients’ vital sign measurements are entered in the Progress Notes folder in the patient chart
F
T/F
Each history section of a patient’s chart consists of multiple notes.
F
T/F
Patient allergies are recorded and stored in the Rx/Medications folder of the patient chart
T
T/F
A typical patient flow consists of check-in, patient intake, exam, and checkout.
T
T/F
The first step in opening a patient chart is to select Open Chart on the file menu or to click the Chart button on the toolbar.
T
T/F
The History dialog boxes are used to select a patient
F
T/F
Using Medisoft Clinical Patient Records, staff members can send intra-office messages
T
T/F
Medications that have been added, discontinued, or changed are noted in the patient chart
T
T/F
The history of present illness (HPI) includes previous treatment and diagnostic tests.
T
T/F
A patient’s chief complaint is recorded in the Medical History folder of the patient chart.
F
The __________ is the patient’s history of medical problems, including chronic conditions, surgeries, and hospitalizations.
past medical history (PMH)
The _________ is information about the patient’s tobacco use, alcohol and drug use, sexual history, relationship status, and other significant social facts that may contribute to the care of the patient.
social history (SH)
The _________ details medical events among members of the patient’s family, including the ages, living status, and diseases of siblings, children, parents, and grandparents.
family history (FH)
The ____________ documents the care delivered to a patient, and the medical facts and clinical thinking relevant to diagnosis and treatment.
progress notes
_________ are sent to patients, other providers, employers, insurance companies, and others.
letters
The ___________ tab is in the Rx/Medications dialog box.
current, ineffective, historical
In the most practices, the _____________ is entered as the title of the progress note for the patient’s visit.
chief complaint
An ______________ is a mild reaction to a medication and doesn’t involve an immune system response.
intolerance
Abnormally high blood pressure readings are highlighted in _________ in the Vital Signs dialog box.
red
To open a new message in the inbox, select the _______ button on the toolbar.
Msg
SH
social history
PMH
past medical history
FH
family history
HPI
history of present illness
ROS
review of systems
PFSH
past, family, & social history