| A | B |
|---|
| Auscultation | listening to sounds using the sthestoscope |
| Four basic level of organization in the body | 1. Cells, 2. Tissues, 3. Organs, 4. Organisms |
| Percussion is defined as | tapping or striking on the body to listen for sounds or air in lungs |
| Otoscope | instrument used to examine the ears |
| Palpation | the sense of touch with a finger or hand, looking for masses or sounds. |
| Manipulation | a forceful and slow movement of a joint, by flexing or extending |
| Ophthalmoscope | to inspect the inner structures of the eye |
| Is the prefix for the heart | MY or CARDIO |
| EKG translates to | Electrocardiogram |
| What are we measuring when doing an EKG | Electrical Impulses |
| If a patient has V-fib, what happen? | Ventricular Fibrilation the patient is death |
| Two disadvantages to paper records | It can be easily misplaced, takes time to file as the files increases more space is needed, only one person at a time can see the records |
| Nine characteristics that define High Quality Medical Records | (varelcomrelrec, timacsecleg) validity, reliability, completeness, relevance, recognizability, timeless, accessability, security, legality |
| HIPAA privacy regulations require what? | requires patient authorization to release information to healthcare facilities or any clearinghouse or healthplans or person. Assure protection to patient's records. |
| Interrupted baseline | when the lead are not connected properly and the EKG shows a flatline and the patient is breathing. |
| Sentinel Event | is any Major Event or death or injury or loss of limb or physical or physchological injury not related to the patient's cause |
| Tachypnea | Fast breathing |
| an Antihypertensive | is used to lower blood pressure |
| Parts of a syringe | Barrel, Calibrated scale, Plunger and tip |
| A tuberculin syringe (TB) holds | 1 ml |
| SC (SQ) is used for | Heparin and insulin medications |
| An Antihistamine | is used to decrease histamine response in the body |
| Buffered or Enteric-coated tablets | can never be scored or broken in half or crushed or dissolved |
| Scored tablets | can be cut in half |
| The larger the gauge number | the smaller the diameter of the needle |
| Dereliction of duty | or failure to perform a duty is negliect |
| ADA requires that people have to have | easy access to a building or entrance |
| The 4 d's of negligence | 1. Duty, 2. Dereliction, 3. Direct cause, 4. Damages |
| Anaphylaxis | A life threatening allergic reaction |
| An example of a vector | Tick, mosquitoe |
| Six steps in the infection chain | 1. infectious, 2. reservoir host, 3. portal of exit, 4. mode of transmission, 5. portal of entry, 6. susceptible host |
| An example of a portal of entry or exit in the infection chain is | the mouth, nose, ear, open wounds |
| Can be treated with antibiotics | Bacteria only |
| Can not be treated with antibiotics | Viral infections |
| Gender or race is knows as a | Risk factor that can not be changed |
| Four types of tissue in the human body | 1. Epithelial, 2. Connective, 3. Muscle, 4. Nervous |
| Mensuration | Is the process of measuring with a flexible tape measure. |
| Describe the structural organization of the human body | The basic unit of life is the cell, cells with sismilar sturctures and functions form tissues that bond together to for an organ, a body system is composed of several organs. |
| Ligaments are included in | the Musculoskeletal System |
| Defibrillator | Machine used to deliver an electroshock to the heart through electrodes placed don the chest wall |
| Infarction | Area of tissue that has died because of lack of blood supply |
| Ischemic | temporary interruption in blood supply to a tissue or organ |
| Myocardium | Heart muscle |
| Diastole | is the relaxation phase of the heartbeat |
| Systole | is the contraction phase of the heartbeat (atria and ventricles contract and empty blood) |
| When running at normal speed, one small 1mm square passes the stylus every... | 0.04 seconds passes the stylus when... |
| With the Wandering baseline | the stylus gradually shifts away from the center of the paper |
| Somatic tremor | shows up on the recording as jagged peaks of irregular height and spacing and a shifting baseline |
| Cardiac Stress | testing is conducted to observe and record the patient's cardiovascular response to measured exercise challenges. |
| A Holter monitor | is a portable system for recording the cardiac activity of a patient over a 24 hour period or longer |
| What information should be analyzed when reading the ECG strip? | Rate, Rythym, P waves, Intervals, Appearance |
| The small square on the ECG represents | One (1 mm) |
| Arrhytmia | An irregular cardiac rhythm |
| Bruit | an abnormal sound or murmur of an organ, vessel, or gland |
| Varicose veins | dilated, tortuous, superficial veins in the legs |
| ACE inhibitors | drugs that ends in pril |
| MVP | Mitral Valve Prolapse |
| Antigen | Foreign substance, that causes the production of a specific antibody |
| Antibody | Immunoglobulin produced by the immune system in response to bacteria, viruses etc. |
| Disinfection | process of killing pathogenic organisms |
| Surgical Asepsis | Destruction of organisms before they enter the body |
| Sanitization | cleansing process that decreases the number of microorganisms |
| Sterilization | Destruction of all microorganisms |
| Signs & Symptoms of inflammation | Erythema (redness), Edema (swelling), Pain, Heat |
| Beta Blockers | has -lol at the end of the generic name |
| Three potentially infectious fluids | CSF Cerebrospinal fluid, Blood, vaginal and semianl secretions, Saliva and human tissue |
| Ownership of medical records | The physician (the maker) or medical facility owns the physical medical record, the patient owns the information contained within it and has access to the information only |
| Two major types of patient records | The paper-based and the computer-based |
| Five basic filing steps: | Conditioning of papers, releasing (ready to file), Indexing (where to file), Sorting (arranging), Storing & Filing |
| When no restriction exists it is best to keep the records for | a 10 year |
| POMR | The problem oriented medical record |
| CBMR | Computer Base Medical Record |
| Objective information | Anything that can be observed or measurable from the patient (yellowed eyes, elevated blood pressure). |
| Subjective information | information that is gained by questioning the patient (patient address, Pain, nausea, dizziness, headache, back pain) |
| what is the ultimate appellate court in the USA | The US Supreme Court, has the authority to interprets and guards the Constitution |
| A defendant in a civil trial is called | The plaintiff |
| Act | the formal action of a legislative body |
| Quackery | The pretense of curing disease |
| Implied Consent | A patient rolls up his sleeve for a blood draw |
| Informed Consent | knowledge of alternate treatments and risks |
| Office Politics | are not always negative |
| Malediction | to speak evil of or curse. |
| Overuse of medical services | are excessive and cause cost increases, like using the emergency room for non emergencies |
| Underuse of medical services | Patients do not take advantage of many services they should be using. |
| Why are third-party payors interested in the information contained in the medical record? | To determine whether claims should be paid |
| Chief Complaing (CC) | The purpose of the patient's visit |
| Past Medical History (PMH) | includes: major illnesses, surgeries, allergies, accidents, immunization record |
| Family History (FH) | Patient's mother and father health, if deceased, cause of death, hereditary or familiar diseases, disorders |
| Social History (SH) | patient's lifestyle, hobbies, entertainment preferences, education, occupation, use of tobacco, alcohol, sleeping habits, excercise, diet, last menstrual period (LMP), birth control, cultural & religious background |
| SOMR stands for | The source-oriented medical record |
| EMR stands for | Electronic Medical Record |
| Database | Record of the patient's name, address, date of birth, insurance information, personal data, history, physical examination, and initial laboratory findings. |
| Bradycardia | A slow heartbeat, pulse below 60 beats per minute |
| Bradypnea | Respirations that are slower than normal in rate |
| Tachycardia | rapid heart rate exceeding 100 beats per minute |
| Tachypnea | Fast breathing or respiration |
| Aanthropometric measurements include | Height, weight, BMI, Fat composition and head and chest circumference |
| Axillary temperatures | are apprx. 1F or 0.6 C lower than accurate oral readings. |
| The tympanic ear temperature | are considered the most accurate because is close to the hypothalamus |
| Three characteristics for measuring a pulse | The rate, Rhythm, volume of the pulse |
| Three characteristics of respirations | The rate, Rhythm, Depth |
| The difference between the systolic and diastolic pressures is | The Pulse Pressure |
| Blood pressure is recorded as a fraction | The systolic being the numerator (top) and the Diastolic the denominator (bottom) |
| First sound- systole | is the contraction of the heart |
| Second sound-diastole | relaxation of the heart |
| Respirations that are counted as nine for 30 seconds are documented as | 9 x 2 = 18 per minute |
| A palpitate blood pressure is taken | is taken without a stethoscope |
| Bevel | Angled tip of a needle |
| Tablet | a compressed powder or granules that break a part in the stomach or in the mouth when wet |
| Capsule | are gelatin-coated and dissolve in the stomach |
| Caplet | are tablets that are solid and oblong similar to capsules but without any coating |
| Suspension | are insoluble drug substances contained in a liquid |
| Inhalation (site of absorption) | the rectum, and the respiratory mucosa |
| Vial | is a small bottle with a rubber stopper through which a sterile needle is inserted to withdraw the single dose of mediation |
| Ampule | is a small hermetically sealed glass flask that contains a single dose of medication |
| Four routes of parenteral administration | Intradermal (ID), subcutaneous (SC), Intramuscular (IM), Z-track Intramuscular injection |
