chief complaint, history of present illness examination, details, drugs and dosages, assessment, return visit information or referral.
POMR (patient oriented medical records)
Soap is most often used in which type of medical record?
basic information such as name, address, telephone number, gender, date of birth, social security number, and employment information.
Patient's family history
information regarding the health of members of the patient's family, includes any diseases, illnesses, and cause of death.
Patient's social History
It provides information about the patients lifestyle. (smoking, drinking, drugs, marital status)
Patient's chief complaint
a statement of the patient's symptoms, nature, and duration of pain. Should include when symptoms were first noticed, patients opinion about the illness, remedies tried, was it a previous condition, other medical treatment for the same problem.
Scale of 1-10
What should a patient use to describe the level of pain that they are experiencing.
the recognition of a disease or injury by symptoms; a critical analysis of the nature of something
attempt to determine which one of several diseases may be producing symptoms
Correction in an electronic medical record.
Patients currently recieving treatment
the records of those patients who have not seen the doctor for six months or longer
containing files of pts who have died, moved, or terminated the relationship
perpetual transfer method
a method of transferring records continuously from active to inactive storage areas whenever they are no longer needed for reference
How long should medical records be kept for an adult?
18 + 3 years
How long should medical records be kept for a child?
If a patient is covered by medicaid or medicare, how long must their files be kept?
Patients should be given an opportunity to claim old records before they are destroyed.
Requests for all medical information must be in _______.
A_______ decides when or if their medical record information should be released.
The form used when a patient decides that they no longer want their medical info shared.
The ________ medical record should never leave the medical facility.
Which type of cabinet requires the least amount of aisle space?
rotary circular files
A SMALL DESKTOP FILE DESIGNED TO ROTATE, THUS PERMITTING THE USE OF BOTH SIDES OF AN INDEX CARD.
upright shelf files; most popular; resembles bookcase; can be located on the wall
They are mounted on tracks in the floor and the units slide along the tracks so that access is gained to needed records. (Used in tight spaces)
Electronic equipment that brings records automatically to the operator; used in hospitals, clinics, and large practices.
used for quick reference of phone numbers and address patient ledgers, patient index, a library index, an index of surgical tray setup.
Metal framework is used to convert a regular drawer into suspension-folder equipment. A portable file cart can also be used.
a necessary filing device, used to identify each shelf, drawer, divider guide, and folder.
conditiong of papers
removing all pins, brads and paperclips; stapling related papers together and
some mark is placed on the file showing that it is ready for filing.
indexing and coding
deciding where to file the letter or paper and placing some indication of the decision on the paper.
grouping by class or kind or size, in sequence.
storing and filing
items faced up top edge to the left with most recent date at front of the folder
last names are considered ________.
using color as an identifying aid in a filing system to divide the alphabetic sections in the storage system.
used for patients who are transitory.
National alliance for Health information technology