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Study sets matching "medical records management"

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Study sets matching "medical records management"

37 terms
Medical Records Management & Medical Documents
accession record
turkey
cross reference
indexing
log book used to assign numbers to correspondence or patients.
Makes my tummy happy
Notation in a file to direct the reader to a specific record…
Selecting the name, subject, or number under which to file a…
accession record
log book used to assign numbers to correspondence or patients.
turkey
Makes my tummy happy
Medical Records Management
accession log
active files
alphabetical filing
archives
Record of numbers assigned to each new patient records
Records belonging to patients currently receiving treatment
Organizing system based on the alphabet usually using the pat…
Storage place for records that are no longer in use but are k…
accession log
Record of numbers assigned to each new patient records
active files
Records belonging to patients currently receiving treatment
15 terms
Managing medical records
Allergy & immunology
Anesthesiology
Bariatric Medecine
Cardiology
The study of asthma and other allergic diseases.
preoperative evaluation of patients to determine conditions t…
is the branch of medicine which deals with obesity and overwe…
the branch of medicine that deals with diseases and abnormali…
Allergy & immunology
The study of asthma and other allergic diseases.
Anesthesiology
preoperative evaluation of patients to determine conditions t…
41 terms
Medical Records Management
Medical Records
Purpose of Medical Record
Paper vs Computer
What Is In A Medical Record
some of the most important documents in vet medicine; it is a…
- to provide an accurate historical account for the vet healt…
- clinic may have paper records or computerized medical recor…
- date of entry... - initials of all team members writing in the…
Medical Records
some of the most important documents in vet medicine; it is a…
Purpose of Medical Record
- to provide an accurate historical account for the vet healt…
29 terms
Medical Records Management
In the SOAPER approach, the letter "E"…
Which of the following is not an impor…
Which of the following is not an advan…
Which of the following patients would…
b. Education for patient
d. you should be good at math
a. Can be used by only one person at a time
d. Amber Davidson
In the SOAPER approach, the letter "E"…
b. Education for patient
Which of the following is not an impor…
d. you should be good at math
38 terms
Medical Records Management
What is the most important ethical rea…
What filing tool could you use to trac…
How should you correct an error in a m…
What type of coding systems are common…
Continuity of patient care
Out guides
In red ink, draw a red line through the error, with the word…
Alphabetic, numeric, and subject
What is the most important ethical rea…
Continuity of patient care
What filing tool could you use to trac…
Out guides
Medical Records Management
Accession Log
Active Files
Alphabetical Filing
Archives
Record of numbers assigned to each new patient record
Medical files of patients who are currently seen in the office
Organizing system based on the alphabet, usually using the pa…
Storage place for records that are no longer in use but are k…
Accession Log
Record of numbers assigned to each new patient record
Active Files
Medical files of patients who are currently seen in the office
12 terms
Medical Records Management
Accession record
caption
cross reference
indexing
logbook used to assign numbers to correspondence or patients
method of designation used on file guides
notation in a file to direct the reader to a specific record…
selecting the name, subject, or number under which to file a…
Accession record
logbook used to assign numbers to correspondence or patients
caption
method of designation used on file guides
21 terms
Practice management medical records
When should the eeceptionist answer th…
Greeting on phone
When scheduling an appointment what ho…
Two types of medical records
2nd ring
Greeting, practice's full name, your name, how may I help you?
Two times (9:30 or 11) morning or afternoon better?
POMR... SOAP
When should the eeceptionist answer th…
2nd ring
Greeting on phone
Greeting, practice's full name, your name, how may I help you?
18 terms
Medical Records & Office Management
Purpose of a Medical Record
What's in a medial record?
Who owns the medical record?
How long is a record kept?
provide information for each veterinarian; serves as a diary…
Patient, Client (owner), patient history, medical/surgical re…
the veterinary facility
1-3 years, most keep for as long as 7 years
Purpose of a Medical Record
provide information for each veterinarian; serves as a diary…
What's in a medial record?
Patient, Client (owner), patient history, medical/surgical re…
12 terms
Chapter 14, medical records management
Accession record (numeric system)
Caption
Cross-reference
Indexing
Log book used to assign numbers to correspondence or patients
Method of designation used on file guides
Notation on a file to direct the reader to a specific record…
Selecting the name, subject, or number under which to file a…
Accession record (numeric system)
Log book used to assign numbers to correspondence or patients
Caption
Method of designation used on file guides
10 terms
Management of Medical Records
A patient is requesting that a copy of…
Medical records storage may be outsour…
Explain the HIPAA confidentiality prac…
What is the best answer to describe wh…
Written consent from patient.
business that specializes in managing and housing documents
the primary goal is to protect the integrity and confidential…
patient parents of minor legal gardian or agent
A patient is requesting that a copy of…
Written consent from patient.
Medical records storage may be outsour…
business that specializes in managing and housing documents
55 terms
Medical Records Management
Inpatient Records
Outpatient Records
Dental Records
Family members of active duty personne…
Contains all admissions paperwork from an MTF
Contain all paperwork from outpatient care received
Contains all paperwork used in the dental clinic
Categories for whom outpatient records are prepared
Inpatient Records
Contains all admissions paperwork from an MTF
Outpatient Records
Contain all paperwork from outpatient care received
25 terms
Medical Records Management
Advanced directives
Narrative notes
Problem-oriented Medical Record charting
Flow charts
documents that outline patients' wishes regarding healthcare…
Written descriptions of patients visits.
Tracks a patient's problems throughout medical care.
Visual tools that help track certain information in patient's…
Advanced directives
documents that outline patients' wishes regarding healthcare…
Narrative notes
Written descriptions of patients visits.
17 terms
CMA Medical Records Management
active medical record
audit
chart
closed medical record
the chart of a patient seen within 2 to 5 years (dependent on…
examine medical record files to ensure accuracy, completeness…
the patient's medical record
the chart of a patient not expected to return to the practice…
active medical record
the chart of a patient seen within 2 to 5 years (dependent on…
audit
examine medical record files to ensure accuracy, completeness…
12 terms
Medical Records Management
accession record
caption
cross-reference
indexing
logbook used to assign numbers to correspondence or patients
method of designation used on file guides
notation in a file to direct the reader to a specific record…
selecting the name, subject, or number under which to file a…
accession record
logbook used to assign numbers to correspondence or patients
caption
method of designation used on file guides
35 terms
Medical Records Management
active patient files
advance directives
chief complaint
closed patient files
files for patients who have appointments or who have been in…
documents that outline patients' wishes regarding health care…
main reason a person seeks healthcare
files for patients who will not be returning to the clinic
active patient files
files for patients who have appointments or who have been in…
advance directives
documents that outline patients' wishes regarding health care…
29 terms
Medical Records Management
In the SOAPER approach, the letter "E"…
Which of the following is not an impor…
Which of the following is not an advan…
Which of the following patients would…
b. Education for patient
d. you should be good at math
a. Can be used by only one person at a time
d. Amber Davidson
In the SOAPER approach, the letter "E"…
b. Education for patient
Which of the following is not an impor…
d. you should be good at math
Medical Records Management
Individual names
Prefixes
Abbreviations and Nicknames
Hyphenation
In a patients name, the surname (last name) is the first inde…
If the last name has prefix, such as Mc, Mac, Van, de, Des, o…
It is recommended that abbreviated first and last names be fi…
Hyphenated names are indexed as one unit, whether first names…
Individual names
In a patients name, the surname (last name) is the first inde…
Prefixes
If the last name has prefix, such as Mc, Mac, Van, de, Des, o…
30 terms
Medical Records Management
Signed informed consent in the medical…
EHR alert
Evaluation and Management (E&M) codes
ABN
means the patient understands treatment
may become part of the medical record, use proper grammar and…
involve 5 components and 2 contributory components. The major…
Advanced Beneficiary Notice -formal notification to the patie…
Signed informed consent in the medical…
means the patient understands treatment
EHR alert
may become part of the medical record, use proper grammar and…
29 terms
Medical Records Management Terms
health information technology (HIT)
practice management (PM) program
electronic health record (EHR)
health informatics
the use of computers and electronic communications to manage…
program used to perform administrative and financial function…
is a computerized lifelong health care record for an individu…
knowledge required to optimize the acquisition, storage, retr…
health information technology (HIT)
the use of computers and electronic communications to manage…
practice management (PM) program
program used to perform administrative and financial function…
25 terms
Medical records management
Accession record
Caption
Indexing
Key unit
Logbook is to assign numbers to patients
method of designation used on file guides
selecting the name, subject, or number under which to file a…
first indexing unit of the filing segment
Accession record
Logbook is to assign numbers to patients
Caption
method of designation used on file guides
medical records management
active records
advantages/benefits of EHR
alphabetical filing
closed records
records of patients who have been seen within the last 3 years
-improved documentation... -avoids medical errors... -health mainte…
Last (surname), first (given name), middle/initial, salutatio…
records of terminated patients
active records
records of patients who have been seen within the last 3 years
advantages/benefits of EHR
-improved documentation... -avoids medical errors... -health mainte…
5 terms
Medical Records Management
Certified Professional Coder(CPC)
Certified Medical Assistant(CMA)
Certified Coding Specialist (CCS)
Certified Medical Reimbursement Specia…
-Accreditation body is the American Academy of Professional C…
-credentialed through the Certifying Board (CB) of the Americ…
-Accreditation body: American Health Information Management A…
-Accreditation body: American Medical Billing Association... -Re…
Certified Professional Coder(CPC)
-Accreditation body is the American Academy of Professional C…
Certified Medical Assistant(CMA)
-credentialed through the Certifying Board (CB) of the Americ…
12 terms
MEDICAL RECORDS MANAGEMENT
what is Record Management?
Record Protection
Types of records
Business records
often referred to as filing, involves arranging and classifyi…
-records should not be taken out, just photocopied... -when not…
Business records, patient records
-financial data related to patient accounts/insurance claim i…
what is Record Management?
often referred to as filing, involves arranging and classifyi…
Record Protection
-records should not be taken out, just photocopied... -when not…
25 terms
Medical Records Management
Accession record
Caption
Chart notes
Cross reference
logbook used to assign numbers to correspondence or patients
method of designation used on file guides
provider's formal or informal notes about presenting problem,…
notation in a file to direct the reader to a specific record…
Accession record
logbook used to assign numbers to correspondence or patients
Caption
method of designation used on file guides
16 terms
medical records management
accession log
active files
alphabetical filing
archives
record of numbers assigned to each new patient record
medical files of patients who are currently seen in the office
organizing system based on the alphabet, usually using the pa…
storage place for records of patients who n o longer seek tre…
accession log
record of numbers assigned to each new patient record
active files
medical files of patients who are currently seen in the office
20 terms
Medical Records Management
Y R medical records ... Important
Continuity of care
WHO (IDCIO)
DHHS
Assistant position in providing the best possible care to the…
Offer legal protection to those who provide care to the patie…
World Health Organizations
Department of health + human services
Y R medical records ... Important
Assistant position in providing the best possible care to the…
Continuity of care
Offer legal protection to those who provide care to the patie…
8 terms
LJS Medical Records Management
Inpatient Records
Outpatient Records
STR (Service Treatment Record)
Three C's of outpatient records
contain all admissions paperwork
contain all paperwork from outpatient care
Outpatient for military members only
Current, concise, complete
Inpatient Records
contain all admissions paperwork
Outpatient Records
contain all paperwork from outpatient care
Medical Records Management
Meaningful Use
Assembling
Filing
Maintenance
involves a series of objectives that eligible professionals m…
place or utilize all the forms or screens used by specific pr…
have active medical records in the secured designated area as…
ensure all documentation is in the medical record in the prop…
Meaningful Use
involves a series of objectives that eligible professionals m…
Assembling
place or utilize all the forms or screens used by specific pr…
78 terms
Medical Records Management
When was HIPAA enacted?
What is the purpose of HIPAA?
What does HIPPAA Privacy Rule do?
Who maintains the overall responsibili…
August 21 1996
To improve the portability and continuity of health insurance…
Governs the protection and privacy of individually identifiab…
MTF Commander
When was HIPAA enacted?
August 21 1996
What is the purpose of HIPAA?
To improve the portability and continuity of health insurance…
54 terms
Chapter 15 Managing Medical Records
active file
alphabetic filing system
closed file
compactible file
files that you use frequently.active file
files are arranged in alphabetic order (last name, first name…
files of patients who have died, have moved away, or for some…
are kept on rolling shelves that slide along permanent tracks…
active file
files that you use frequently.active file
alphabetic filing system
files are arranged in alphabetic order (last name, first name…
13 terms
Medical Records Management
Contain all admissions paperwork from…
Contains paperwork from care received
Contains all paperwork used in dental…
Family members of AD personnel belong…
Inpatient
Outpatient Record
Dental Record
Outpatient
Contain all admissions paperwork from…
Inpatient
Contains paperwork from care received
Outpatient Record
15 terms
Managing Medical Records
Medical Record
Electronic Medical Record
Chronological Medical Record
POMR
The source of all documentation relating to the patient. The…
A computerized means of gathering, documenting and storing in…
Follows the patient over a period of time, with each visit co…
problem oriented medical record is used to identify patient p…
Medical Record
The source of all documentation relating to the patient. The…
Electronic Medical Record
A computerized means of gathering, documenting and storing in…
25 terms
Managing medical records
Advantage of filing shelves.
Filing cabinet.
Horizontal filing cabinets.
Compactible files.
Allows several people to retrieve files at the same time.
Best used by one person.
Requires more wall space. It is a later file.
Rolling shelves that slide along tracks in the floor.
Advantage of filing shelves.
Allows several people to retrieve files at the same time.
Filing cabinet.
Best used by one person.
25 terms
Medical records management/ medical documents
Accession record
Caption
Cross reference
Indexing
Log book used to assign numbers to correspondence or patients
Method of designation used on file guides
Notation in file to direct reader to specific record that may…
Selecting name subject or number under file to record and det…
Accession record
Log book used to assign numbers to correspondence or patients
Caption
Method of designation used on file guides
25 terms
Managing medical records
Advantage of filing shelves.
Filing cabinet.
Horizontal filing cabinets.
Compactible files.
Allows several people to retrieve files at the same time.
Best used by one person.
Requires more wall space. It is a later file.
Rolling shelves that slide along tracks in the floor.
Advantage of filing shelves.
Allows several people to retrieve files at the same time.
Filing cabinet.
Best used by one person.
20 terms
Managing Medical Records Vocab
File guide
Vertical file
Active file
Unit
Separates the contents in a file drawer
File cabinet that is taller than it is wide
File that is used frequently
Each part of a name or numerical sequence
File guide
Separates the contents in a file drawer
Vertical file
File cabinet that is taller than it is wide
15 terms
Managing Medical Records
active records
addendum
alphabetic filing
chronological medical record
medical files of patients who are currently being seen by the…
addition to the original document
filing system based on the letters of the alphabet
patient record that follows the patient over a period of time…
active records
medical files of patients who are currently being seen by the…
addendum
addition to the original document
24 terms
Managing Medical Records
Active file
Alphabetic filing system
Closed file
Coding
A file used on a consistent basis
A filing system in which the files are arranged in alphabetic…
A file for a patient who has died, has moved away, or for som…
Putting an identifying mark or phrase on a document to ensure…
Active file
A file used on a consistent basis
Alphabetic filing system
A filing system in which the files are arranged in alphabetic…
13 terms
Managing paper medical records
active records
Alphabetic filling
Chronological medical record
closed records
medical file of patients who are currently being seen by the…
filling system that uses the e alphabet to file
pt record that follows the pt over a period of time, with eac…
records of patients whom have died or indicated they are no l…
active records
medical file of patients who are currently being seen by the…
Alphabetic filling
filling system that uses the e alphabet to file
19 terms
(Chapter 13) Managing Medical Records
A medical record contains:
chronological medical record
problem-oriented medical record (POMR)
SOAP
Patients past medical records, history and physical, insuranc…
follows patient over a period of time
chart by patient problems... 4 parts: database, problem list, pl…
subjective ( Pt. belief) objective (observed) assessment (dia…
A medical record contains:
Patients past medical records, history and physical, insuranc…
chronological medical record
follows patient over a period of time
18 terms
Managing Medical Records
Vertical Filing
Lateral Filing
Compatible Files
Tickler File
Features pull out drawers that usally contain a metal frame o…
Often features doors that flip up and pullout drawers.
Kept on fooling shelves that slide along permanent tracks on…
Date ordered reminder file.
Vertical Filing
Features pull out drawers that usally contain a metal frame o…
Lateral Filing
Often features doors that flip up and pullout drawers.
40 terms
Medical Records Management & Medical Documents
accession record
caption
cross reference
indexing
log book used to assign numbers to correspondence or patients.
Method of the designation used on file guides.
Notation in a file to direct the reader to a specific record…
Selecting the name, subject, or number under which to file a…
accession record
log book used to assign numbers to correspondence or patients.
caption
Method of the designation used on file guides.
15 terms
MANAGING MEDICAL RECORD
Medical Record
Chronology medical record
POMR
4 tapes of POMR
historical and physician,progress notes, insurance informatio…
follow patient period of time,each visit,new entry by date.
list patientd problem found in the front of chart .
Database, Problem list, Plan, Progress notes.
Medical Record
historical and physician,progress notes, insurance informatio…
Chronology medical record
follow patient period of time,each visit,new entry by date.
26 terms
Medical Records Management Chap 8
Medical records are the property of who?
Information in the medical record belo…
Who is the information in the medical…
Medical facilities generate a large am…
The physician
The patient
HIPPA
Information
Medical records are the property of who?
The physician
Information in the medical record belo…
The patient
27 terms
CHAPTER 10: MEDICAL RECORDS MANAGEMENT
active patient files
advance directives
Center for Medicare and Medicaid Servi…
chief complaint
files for patients who have appointments or who have been in…
documents that outline patients' wishes regarding health care…
agency that oversees Medicare and Medicaid services
main reason a patient seeks care
active patient files
files for patients who have appointments or who have been in…
advance directives
documents that outline patients' wishes regarding health care…
34 terms
ch.8 medical records management
info on a medical record belongs to wh…
what is the greatest bulk of info gene…
when shod the original record be relea…
what are essential for patient care
belongs to pt and is protected under HIPAA
medical records
1.- when subpoenaed by a court of law... 2.-when dr retires
accurate medical records
info on a medical record belongs to wh…
belongs to pt and is protected under HIPAA
what is the greatest bulk of info gene…
medical records
Managing Medical Record
Medical Record
Electronic Medical Record (EMR)
Medical Record
Chronological medical record
Is all the source of all documentation ralating to the patien…
Somtimes called an electronic health record (EHR),in a comput…
It contains all written documentation that relates to the pat…
Follows the patient over a period of time,with each visit con…
Medical Record
Is all the source of all documentation ralating to the patien…
Electronic Medical Record (EMR)
Somtimes called an electronic health record (EHR),in a comput…
28 terms
Ch. 14 Medical Records Management
Physically, who owns the medical record?
The information on the medical record…
Medical facilities generate...
Why should providers involve their pat…
The medical record is the property of physician creating the…
...the patient and is protected with privacy & confidentialit…
...a large amount of information; the greatest bulk of inform…
to foster trust and respect with their patients
Physically, who owns the medical record?
The medical record is the property of physician creating the…
The information on the medical record…
...the patient and is protected with privacy & confidentialit…
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