49 terms

kinns ch14 the paper medical record

STUDY
PLAY

Terms in this set (...)

alpabetic filing
Any system that arranges names or topics according to the sequence of the letters in the alphabet
alpha numeric
Consisting of or using both letters and numbers
audit
an inspection of the accounting procedures and records by a trained accountant or CPA
augment
enlarge or increase
caption
a heading, title, or subtitle under which records are filed.
chronologic order
Of, relating to, or arranged in or according to the order of time.
continuity of care
continuing of patient care from one physician to another
dictation
the act of saying words for someone else to write down
direct filing system
a filing system without source of reference
gleaned
Gathered bit by bit (e.g. information or material); picked over in search of relevant material
indirect filing system
a filing system in which an intermediary source of reference, such as a file card, must be considered to locate specific files is called a:
microfilm
film on which materials are photographed at greatly reduced size
numeric filing
The filing of records, correspondence, or cards by number.
objective information
information that is gathered by watching or observation of a patient.
obliteration
Act of making undecipherable or imperceptible by obscuring or wearing away.
OUTfolder
a folder used to provide space for the temporary filing of materials
OUTguide
A heavy guide that is used to replace a folder that has been temporarily moved from the filing space.
power of attorney
a legal instrument authorizing someone to act as the grantor's agent
pressboard
a strong, highly glazed composition board resembling vulcanized fiber; heavy card stock.
procrastination
Intentionally putting off doing something that should be done
provisional diagnosis
A temporary diagnosis made before all test results have been received.
purging
The process of moving active files to inactive status.
quality control
the processes an organization uses to maintain its established quality standards
requisits
required or nessisary for a particular purpose
retension schedule
A method or plan for retaining or keeping medical records.
shelf filing
A system that uses open shelves rather than cabinets for storing records
shingling
filing in which a report is laid on top of the older report, resembling the shingles of a roof.
subjective information
Information that is gained by questioning the patient or taken from a form.
tickler file
A chronologic file used as a reminder that something must be taken care of on a certain date.
transcription
a written copy of something made either in long-hand or by machine
vested
Granted or endowed with a particular authority, right, or property; to have a special interest in
source-oriented records
organized according to the source of documented information
problem-oriented records
are organized around the patient's problems
SOAP
subjective, objective, assessment, plan, Often used in the POMR plan
CHEDDAR
Chief complaint, History of present illness Examination, details, Drugs and Dosages, Assessment, Aeturn visit Information or Referral
personal demographics
identifying factors-correct full name, name of parents if pnt is a child, age, gender, date of birth, marital status, income, name of spouse if married, no. of children, home add, phone no, e-mail add, occupation, empl info for spouse, health ins info, ssn
laboratory reports
Instances of infection or disease in individuals confirmed by laboratory tests.
radiology reports
description of the findings and interpretations of the radiologist who studies the X-ray images taken of a patient
addendum
when a correction is made at a later date for hand written documents
perpetual transfer method
a method of transferring records continuously from active to inactive storage areas
machine transcription
dictating into a dictation unit/--istening to what was dictated--keying the dictated text to a printed document using correct format and punctuation
indexing and coding
deciding where to file the letter or paper and placing some indication of the decision on the paper
indexing rules
last name first, then first name, then middle name or initial, terms of seniority are used only to distinguish from another identical name
subject filing
arranging files according to their title,
grouping similar subjects together.
differential diagnosis
attempt to determine which one of several diseases may be producing symptoms
final diagnosis
Conclusion a physician reaches after evaluating all findings, including lab and other test results
active files
patients currently receiving treatment
inactive files
Patients who have not been seen for about 6 months to a year
closed files
patients who have died, moved away, or otherwise discontinued treatment