48 terms

Chapter 14

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Alphabetic Filing
Any system that arranges names or topics according to the sequence of the letters in the alphabet.
Alphanumeric
Of or relating to systems made up of combinations of letters and numbers.
Audit
A formal examination of an organization's or individual's accounts or financial situation; a methodic examination and review.
Augment
To make greater, more numerous larger, or more intense.
Caption
A heading, title, or subtitle under which records are filed.
Numeric Filing
The filing of records, correspondence, or cards by number.
Objective Information
Iinformation gathered by watching or observing a patient.
Obliteration
The act of making undecipherable or imperceptible by obscuring or wearing away.
Procrastination
Intentional postponement of 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 files.
Retention Schedule
A method or plan for retaining or keeping medical records, as well as their movement from active, to inactive, to closed filing.
Shingling
A method of filing in which a report is laid on top of the older report, resembling the shingles of a roof.
Subjective Information
Information gained by questioning the patient or taking it from a form.
Tickler File
A chronologic file used as a reminder that something must be delt with on a certain date.
Vested
Granted or endowed with a particular authority, right, or property; to have a special interest in.
4 reason medical records are kept
1. Medical record helps the physician provide the best medical care for the patient. 2. Medical records are kept as legal protection for those who provide the care to the patient. 3. Medical records provide statistical information. 4. Medical records are vital for financial reimbursment.
Ownership of medical records
The records belong to the physician and the information on the record belongs to the patient.
2 major typs of medical records
1. Paper medical records 2. Electronic medical records
S.O.A.P
Subjective. Objective. Assessment. Plan
C.H.E.D.D.A.R
Chief of complaint. History. Examination. Details (of problem and complaints). Drugs and dosages. Assessment. Return visit information, if applicable
Personal Demographics
the identifiable characteristics of individuals and groups of people (age, sex, family size, income, occupation, education)
Revocation Form
The form used when a patient decides that they no longer want their medical info shared.
Inactive Files
files of patients that have not been seen over the past 3 years
Active Files
frequently used files
Progress Notes
Notes used in the patient chart to track the progress and condition of the patient.
POMR
Problem Oriented Medical Record
Closed Files
containing files of pts who have died, moved, or terminated the relationship
Color-Coding
using color as an identifying aid in a filing system to divide the alphabetic sections in the storage system.
Laboratory Reports
Usually displayed on a progression graph - demonstrates change in status
E-Record can be viewed individually or in a cumulative fashion - contains graphs that indicate changes in the patient's status
In E-Record divided by test category
Lab sheets can be individual and show only tests ordered with this blood draw - Nursing homes - done by independent labs
Radiology Reports
description of the findings and interpretations of the radiologist who studies the X-ray images taken of a patient
AMA
American Medical Association Council on Ethical and Judicial Affairs
HIPAA
Health Insurance Portability and Accountability Act privacy rules does not include requirments for the retention of medical records. However, the privacy rule does require that appropriate administrative, techinical, and physical safeguards be applied so that the privacy of medical records is maintained.
Protection of Records
The prevention of unauthorized disclosure of personally identifiable information pertaining to a child.
Reliability: refers to the extent to which an instrument is consistent in measuring whatever it purports to measure
medical records management system
Sould provide an easy method of retrieving information. The files should be organized in an orderly fashion, and all information in the record must be completely legible to the average reader. The information should also be accruate, and corrections should be made and documented properly.
Source Oriented Records
traditional record, each discipline makes notations in a seperate section, information about a particular problem distributed throughout the record
Medical case History
Is the most important record in a physician's practice. The completeness, each patient's record should contain subjective information provided by the patient and objective information provided by the physician.
Patient Chief Complaint
is a concise account on the patient's own words.
Dianosis
it may be labeled a provisional diagnosis. the process of weighting the probability onf one disease causing the patient's illness against the probability that other disease are causative.
Corrections to medical records
to corret a handwritten entry: draw a line through the error. Insert the correction above or immediately after the error, in spot where it can be read clearly. if indicated by the policy and procedures manual, write "correction" or "corr." in the margin. The person making the correction should write his or her initials or signature below the correction and date. follow the format indicated in the policy and procedures manual.
Alteration to medical records
never attemp to alter medical records without using this specific correction procedure, becasue this alteration of records may indicate a fraudulent attempt to cover up a mistake made by a staff member or the physician.
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
Dictation Unit
the physician uses it unit to record material to be typed. desktop dictatin unit is common in an office.
voice recognition software
is used for transcription, are loaded onto an office computer and work through a usb port or the line-in jack of a telephone. (record approximatel 125 per minute and 98% accuracy).
Filing equipment
the most popular system today is color-coding on open shelves. some factors that should be considered when selecting filing equipment are: office space availiability. structural consdierations. cost of space and equipment. size, type, and volume of records. confidentiality requirements. retrieval speed. fire protection.
Divider Guides
recommend one guide for approximately each 1/2 inches of material, or every eight to 10 folders. they seperate files
OUTguides
These are beneficial in locating records that have been removed and are unreturned.
File folders
variety of formats. made of heavy stock paper; used to store documents, patient record forms and business reports
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