digital signature - when a note is signed electronically, the provider is representing that everything
within the note is correct
A medication list must be reconciled and updated in the EHR during each patient encounter. t or f -
true
A medication reconciliation software does not eliminate the ...
GG MOA 160 EHR chapter 6
digital signature - when a note is signed electronically, the provider is representing that everything
within the note is correct
A medication list must be reconciled and updated in the EHR during each patient encounter. t or f -
true
A medication reconciliation software does not eliminate the need to transcribe the providers office
notes. t or f - false
A patient is asked for his or her allergy history only during the visit. t or f - false
acute condition - An episodic illness or injury of limited duration that responds well to treatment.
allergies are... - 1.documented at every visit
2. document corresponding reactions
anthropometric measurements - The height, weight, and size of the human body.
chief complaint - A brief statement of the problem, condition, or symptoms that prompted the
patient to seek medical care.
chief complaint, CC or cc - the patients main reason for seeking medical care
chronic condition - A prolonged illness that requires periodic follow-up.
document allergy categories - 1. environment
, 2. seasonal
3. contact
4. food
documentation in the EHR - 1. makes diagnosis and treatment more efficient
2. promotes patient safety and reduces medical errors
3. serves as a risk management function by providing evidence of communication
4. proper documentation in EHR allows related items such as health history, progress notes, patient
letters and patient instructions to be linked
documenting patient history - 1. medical and surgical history
2. family history
3. social history
E-visit - A physician consultation with an established patient using a secure internet service.
E-visits are illegal in most states. t or f - false
high-alert medication - A medication that poses a heightened risk of injury or death when
improperly administered.
history of the present illness - The duration, location, severity, context, associated signs and
symptoms, quality, and modifying factors related to a patients illness.
HPI, history of present illness - 1. symptoms
2. duration
3. timing
4. modifying factors
5.associate signs and symptoms
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