47 terms
Kinns chapter 14
STUDY
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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)
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When the file is no longer active due to patient passing away, or patient has moved away, or physician has terminated the relationship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)
(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
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
25%
Physician's using electronic health records in U.S.
Computer based and paper based medical records
Both have advantages and disadvantages