Question

Using your critical-thinking skills, play the role of an administrative medical assistant as you answer each question.

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) You retrieve a patient’s medical record and notice that the abbreviation WDWNYM 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 young male.” What do you do with this information?

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

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

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

Answer 1

Q. No. 1. Answer :

* if there is no date on several charts of lab reports first I should ask the who collected lab reports, and that day shift staff, and by seeing continuation notes, we can put dates, before that I will ask the staff who maintained that case, why they did not mention the date.

* and after the hand over they will mention sign and date that date we will consider.

Q. No. 2. Answer :

That unapproved abbreviations should not be used, if they are using it is local purpose.

But not standard purpose, so they can not maintain that abbreviations.

Q. No. 4. Answer :

I will suggest your medical records will safe with us as an electronic system, you should not have any problem, when ever you need we will supply and give you for your emergency like that I will say.

Q. No. 5. Answer :

What ever the words I am not understanding and I'm not sure, that time I will clarify that doubt by concern physician and I should transcribing that matter correctly.