47 terms

Kinns chapter 14

STUDY

PLAY

Terms in this set (...)

Alphabetic Filing

Any system that arranges names or topics according to the sequence of the letters in the alphabet

Audit

A formal examination of an organizations or individuals accounts or financial situation; a methodic examination and review

Chronologic order

Of, relating to, or arranged in or according to the order of time

Continuity of care

Continuation of care smoothly from one provider to another, so that the patient receives the most benefit and no interruption in care

Dictation

The act or manner of uttering words to be transcribed

Numeric filing

The filing of records, correspondence, or cards by number

Objective information

Information gathered by watching or observing a patient

OUTguide

A heavy guide used to replace a folder temporarily removed from the filing space

Pressboard

A strong, high glazed composition board resembling vulcanized fiber; heavy card stock

Procrastination

Intentional postponement of doing something that should be done

Purging

The process of moving active files to inactive status

Quality control

An aggregate of activities designed to ensure adequate quality, especially in manufactured products or in the service industries

Requisites

Entities considered essential or necessary

Reverse chronologic order

Arrange in order so that the most recent most recent item is on top and older items are filed further back

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 question the patient or taking it from a form

Ticker file

A chronologic file as a reminder that something needs to be dealt with on a certain date

Organizing a medical record

Problem- oriented (healthy-related correspondence)
Source-oriented (general correspondence)
Chronologically (practice management files and miscellaneous files)

To protect the physician in actions during medical professional liability proceeding

Purpose of accurate and maintained medical records

Response

"R" entry in SOAPER

Education

"E" entry in SOAPER

Subjective Impression

"S" entry in SOAPER

Objective clinical evidence

"O" entry in SOAPER

Assessment or diagnosis

"A" entry in SOAPER

Plans for further studies, treatments, or management

"P" entry in SOAPER

Closed

When the file is no longer active due to patient passing away, or patient has moved away, or physician has terminated the relationship

Must be kept in medical record

Patient consent form

Releasing records

Includes adding mark that indicates that the documents are ready to be filed

Alphabetically

Names should be filed

Proper index of persons with the same name

Person with a title such as , MD would be listed first

Alphabetically, Numeric, Alphanumeric

Basic filing method

Color coding

Can be used for both medical record and business records

The physician or prodder who created it

The physical medical record belongs to who?
(The patients medical record should never leave the office)

Rotary circular files, Lateral files, Automated files

Types of Equipment found in a medical office

Adding information to a patients chart

Most recent information should be on top in the medical record

The patient

Who ultimately decides if a medical record can be released?

Cost of space, Confidentiality requirements, Fire protection

Things a medical assistant should consider when selecting filing equipment

Chief complaint

Is the main problem patients are currently experiencing (Medical assistant should note other remedies the patient has tried, duration of the pain, and the time when symptoms were noticed

New file preparation

Make sure patients name is spelled correctly
Review forms the patient fills out for completeness
Make a copy of insurance card or make sure insurance information is included

"If it was not charted, it did not happen"

Medical assistant should remember about documentation

Power of attorney

A legal instrument that authorizes a person to act as the agent of the grantor

HIPAA

Does not recommend how many years a physician must keep patients records

Keeping records on minors

Until the age of maturity (18) plus 3 years

Draw a line through the error, date and initial

Correcting an error in the medical record

To protect the patient health and well-being

Importance of reporting to physician when an error in charting is discovered later