Medical documents, medical record management week 3


Terms in this set (...)

method of designation used on file guides
selecting the name, subject, or number under which to file a record and determining the order in which the units should be considered
Key unit
first indexing unit of the filing segment
Out card
out sheets are devices to help in tracking charts.
As information accumulates, it is necessary to maintain files by the process
source-oriented medical record (SOMR)
a type of patient chart record keeping that includes separate sections for different sources of patient information, such as laboratory reports, pathology reports, and progress notes
Tickler File
Reminder file
each part of a name (business or person), words, or numbers that will be indexed and coded for filing
Chart notes
(also called progress notes) provider's formal or informal notes about presenting problem, physical findings,and plan for treatment for a patient examined in the office, clinic, acute care center, or emergency department
Chief complaint
description of symptoms, problems, or conditions that brought the patient to the clinic
Discharge summary
medical reports that document the hospitalization history of a patient
Gross examination
The view of the naked eye
Health Insurance Portability and Accountability Act
government rules, regulations, and procedures resulting from legislation designed to protect the confidentiality of patient information (Ch. 7, 16).
Out sourcing
the practice of contracting with a service outside of the clinic or hospital to a company where the task can be accomplished at a lower cost and with a faster turnaround time
Operative report
chronicles the details of a surgical procedure performed in a hospital, outpatient surgical center, or clinic
Progress notes
also called chart notes. Provider's formal or informal notes about presenting problem, physical findings, and plan for treatment for a patient examined in the office, clinic, acute care center, or emergency department
Quality Assurance
process to provide accurate, complete, consistent health care documentation in a timely manner while making every reasonable effort to resolve inconsistencies, inaccuracies, risk management issues, and other problems
Review of system
inquires about the system directly related to the problems identified in the history of the present illness
Active record
medical record of pt that was seen within last 2-3 yrs
Terminal digit filing
Filing by the last group of a set of digits (numbers)
Color coding
is a technique often used in the three major filing systems. allows immediate recognition if a chart is misfiled.
optical character recognition
Retention Period
Length of time a facility will maintain an archived record.
a medical visit
Alphabetical Identification
The simplest form of record identification is alphabetic, using the patient's name to identify and file the patient's health record.
Serial Numbering
In this system, each time a patient is registered, a new patient number is assigned and a new patient record is created.
Centralized filing
The records of the patients are filed in one location.
Master Patient Index
a card file (or computerized file) that contains an alphabetical listing and information on all patients treated by a health facility. (Amount of information included depends on needs of facility.)
Barcode Device
Barcode scanner reads bar codes