Ch 14/16

Question 0

Method of designation used on file guides

Answer 0

Caption

Question 1

Logbook used to assign numbers to correspondence or patients

Answer 1

Accession record

Question 2

Notation in a file to direct the reader to a specific record that may be filed under more than one name/subject where the surname is not easily recognizable

Answer 2

Cross-reference

Question 3

Selecting the name, subject,or number under which to file a record and determining the order in which the units should be considered

Answer 3

Indexing

Question 4

First indexing unit of the filing segment

Answer 4

Key unit

Question 5

Card, Folder or slip of paper inserted temporarily in the files to replace a record that has been retrieved from the files

Answer 5

Out guide

Question 6

A type of patient chart record keeping that uses a sheet at a prominent location in the chart to list vital identification data

Answer 6

Problem-oriented medical record (POMR)

Question 7

Method of maintaining order in the files by separating active from inactive and closed files

Answer 7

Purging

Question 8

Acronym for patient progress notes based on subjective impressions (S), objective clinical evidence (O), assessment or diagnosis (A), and plans for further studies (P)

Answer 8

SOAP/SOAPER

Question 9

A type of patient chart record keeping that includes separate sections for different sources of patient information, such as laboratory reports, pathology reports, and progress notes

Answer 9

Source-orientated medical record (SOMR)

Question 10

System to remind of action to be taken on a certain date.

Answer 10

Tickler file

Question 11

Each part of a name, words, or numbers that will be indexed and coded for filing

Answer 11

Unit

Question 12

(Progress notes) provider’s formal or informal notes about presenting problem, physical findings, and plan for treatment for a patient examined in the office, clinic, acute care center, or emergency department

Answer 12

Chart notes/Progress notes

Question 13

Specific symptom or problem for which the patient is seeing the provider today

Answer 13

Chief complaint (CC)

Question 14

Medical reports that document the hospitalization history of a patient

Answer 14

Discharge summary (DS)

Question 15

Patient medical record from a single medical practice, hospital, or pharmacy

Answer 15

Electronic Medical Record (EMR)

Question 16

Viewing specimens with the naked eye

Answer 16

Gross examination

Question 17

Government rules, regulations, and procedures resulting from legislation designed to protect the confidentiality of patient information

Answer 17

Health insurance portability and accountability act (HIPAA)

Question 18

The chronological description of the development of the patient’s illness

Answer 18

History of the present illness (HPI)

Question 19

The practice of contracting with a service outside of the clinic or hospital to a company where the task can be accomplished at a lower cost and with a faster turnaround time

Answer 19

Outsourcing

Question 20

Medical report that chronicles the details of a surgical procedure

Answer 20

Operative report (OR)

Question 21

Medical reports generated to describe the gross and microscopic examinations performed during a surgical procedure

Answer 21

Pathology report

Question 22

Process to provide accurate , complete, consistent health care documentation in a timely manner while making every reasonable effort to resolve inconsistencies, inaccuracies, risk management issues and other problems

Answer 22

Quality assurance (QA)

Question 23

Inquires about the system directly related to the problems identified in the history of the present illness

Answer 23

Review of systems (ROS)