Medical ol-tice proceduri. S, Seventh edition

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Part 2 • Administrative Responsibilities

4.8 Discuss the various input j » Newer input technologies, such as voice-technologies used to create recognition software, wireless devices, and medical documentation. PDAs, allow the input of data with greater speed Pages 166-170 and mobility. This, in turn, allows more time for

patient care.

Voice-recognition software enables the dic­tator to train the program to his or her voice, and data are input by speaking into the trained device.

-" Wireless technology, such as Smartphones, allow the input of medical data into extremely small, portable devices. WiFi connection is now available at many locations, allowing data to be input directly into a patient's elec­tronic health record. A physician visiting a patient in the hospital can research medical contraindications from his or her wireless device without the need to leave the patient's room or the facility. Traditionally, transcription has been used for medical data input. Physicians dictate data into recording devices and transcriptionists key in transcribed documents for the physi­cian's verification and signature. The field of transcription is evolving, just as technology continues to evolve. Transcriptionists will be needed to edit medical data entered through electronic devices, such as voice recogni­tion. Opportunities for "scribes"—individuals who input patient medical data into elec­tronic storage as the physician dictates or provides data—exist for individuals with tran­scription training and/or experience.

Soft Skills Success


Effective teamwork can produce incredible results, but teamwork does not just happen. It takes a great deal of work and compromise. Knowing how to work on or with a team will be crucial to your success. Before we can reward teamwork and collaboration that inte­grates care, we need applications that let clinicians communicate patient information in­stantly and securely. How can teamwork be beneficial to EHR and the medical office?

Chapter 4 • Managing Health Information


Chapter J'.;. j Review Questions connect


Match the term or phrase on the left with the correct answer on the right.


(LO 4,1) Word processing


The use of radio waves to transmit data


(LO 4.3) SOAP


A record of removed information


(LO 4.4) Active record


Records that provide proof of legal medical


(LO 4.1) File server



(LO 4.5) Out indicator


Software program used to enter, edit, for-

mat, and print documents


(LO 4.6) Electronic health record


Technology used to input data using speech


(LO 4.2) Medicolegal



(LO 4,3) ROS


Heath care databases that work together to


(LO 4.8) Wireless communication

compile complete patient healthcare records


(LO 4.8) Voice-recognition


Medical documentation format that in-


cludes subjective and objective data, assess-

ment of data, and course of treatment

h. A subjective assessment of pertinent body systems

i. Records of current patients

j. Centralized storage of shared network elec­tronic data

CHECK YOUR UNDERSTANDING Select the most correct answer.

1. (LO 4,1) Maria works exclusively inputting data into medical records. She seldom takes a break from inputting and works 4 days per week, 10 hours each day. While driving, she noticed a change in her distance vision. Which of the following should she do to help ease eye strain while working?

a. Place her hands and wrists in horizontal alignment

b. Regularly focus on a distant object

c. Place source documents flat beside her computer

d. Frequently rotate her neck and shoulders

2. (LO 4.2) Lori works for a medical practice that uses the first three letters of the patient's last name and the date of birth as patient numbers. When Lori was filing medical insurance claims, she noticed that a chart note had been made in the wrong chart. The physician sees twin females, and the chart for the wrong twin had been noted. To correct the error, she should

a. Eliminate the chart note with correction fluid.

b. Use a wide, permanent black marker to cross out the chart note.

c. Place a straight line through the entry, making sure it is still legible; mark it "error"; date her correction; and initial the correction.

d. Place a wavy line through the entry, making sure it is still legible; mark it "error"; date her correction; and initial the correction.

Part 2 • Administrative Responsibilities

3. (LO 4.3) When Dr. Lee opened the EHR for his next patient, he was able to quickly view a listing of all the patient's current and previously treated medical conditions. Which documentation format does Dr. Lee use?





4. (LO 4.4) After 10 years of practice, the administrative medical assistant observed that the medical charts container was full and hardcopy records were hard to retrieve and return due to overcrowding. No retention schedule had yet been developed. Which of the following strategies could be used effi­ciently to ease the overcrowding?

a. Shred all records for patients who have not been seen in three years or more

b. Retrieve all the inactive folders and place them in a corner

c. Remove and shred all files for deceased patients

d. Remove folders for inactive and closed files and move them to a secure, secondary location

5. (LO 4.5) Medical records in the office are marked with the patient number in the upper right-hand corner of the documents. This is known as

a. Inspecting a document.

b. Indexing a document.

c. Coding a document.

d. Storing a document.

6. (LO 4.6) Because of the high cost of EHR implementation and anticipated software updates, which of the following should not be considered when purchasing a program?

a. A software program package that does not include future updates as part of the initial cost or at a stated cost

b. Availability of ongoing software training by the manufacturer

c. Ease of use

d. Information from others who use the software

7. (LO 4.7) Which of the following is an acceptable chart notation for "as needed"?

a, q.4h

b, p.r.n.

c. a.n.

d. as ndd

8. (LO 4,8) Jamie does transcription for a local multi-physician practice. She has heard about the imple­mentation of EHRs and is concerned about the future of her position. Which of the following would be beneficial for Jamie?

a. Immediately resign from her position and return to school for training in a different field

b. Become involved in the selection process of an EHR program and contribute observations on the documentation template

c. Continue to update herself on grammar, punctuation, and format

d. Both b and c are beneficial options for Jamie.

Chapter 4 • Managing Health Information


Be sure that you are familiar with the following terms:

adnexa accessory parts to the main structure amoxicillin an antibiotic anginal relating to constricting chest pain bronchitis inflammation in the bronchi bruit murmur

colonoscopy visualization of the colon with a scope costochondritis inflammation of the cartilage between the ribs dysmenorrhea menstrual cramps dysuria painful or difficult urination

ecchymosis black and blue or purple skin discoloration; bruise exudative relating to tissue material deposited as a result of infection gallop an abnormal heart sound hepatosplenomegaly liver and spleen enlargement

injection inserting a solution under the skin (subcutaneously, intravenously, or intra­muscularly) using a syringe or a needle lymphadenopathy enlargement of lymph nodes malaise feeling of uneasiness normocephalic relating to a normal-size head ophthalmic relating to the eye otitis media inflammation of the ear PE tubes polyethylene tubes pharyngitis inflammation of the throat rhonchi musical pitch heard on chest auscultation sclera the white of the eye

Sitz bath a type of bath that consists of soaking the area from the tailbone to the

lower abdomen in a tub of warm water supple easily moveable

tinea cruris a fungal infection in the male perineal or groin area tonsillitis inflammation of the tonsils


These questions cover the most important points in this chapter. Using your critical-thinking skills, play the role of an administrative medical assistant as you answer each question. Be prepared to present your responses in class.

1. You are going through a patient's medical record to find information on a specific lab report, and you notice that several chart notes are not dated. What should you do?

2, How does the use of the SOAP format for record keeping minimize a provider's exposure to legal risk?

Part 2 • Administrative Responsibilities

3. You retrieve a patient's medical record and notice that the abbreviation WDWNWF is used several times in the chart notes. You know that this is not an approved abbreviation, though you eventually figure out that it stands for "well-developed, well-nourished white female." What do you do with this information?

4. You are asked to retrieve information regarding a patient's family history of intestinal cancer. The physician generally uses the POMR format. Where in the file should you look?

5. A former patient calls, hoping to locate x-rays taken more than five years ago. What should you say?

6. A patient calls and is moving out of town. She is concerned about her medical record. What would you suggest?

7. You are transcribing the physician's dictation and cannot understand several words in a chart note. What do you do?

Chapter 4 • Managing Health Information

Simulation 1

Welcome to the practice of Dr. Karen Larsen! Today, you begin to apply the skills you have learned in this text as you assume the role of Linda Schwartz, Dr. Larsen's administrative medical assistant.

Simulation 1 is the first of three simulations in the text. These simulations provide practical experience in working in a physician's office. You will discover how various tasks relate to each other. The daily

events in the office are narrated on the Simulation

Recordings that accompany the text. As you listen to

the recordings, you will handle various assignments

as the assistant. Your simulation work will include

making and canceling appointments, preparing mes- n

sages, creating communications, preparing various J.

medical forms, and following through on daily tasks. @

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