Ch 14/16 Flashcards
Method of designation used on file guides
Caption
Logbook used to assign numbers to correspondence or patients
Accession record
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
Cross-reference
Selecting the name, subject,or number under which to file a record and determining the order in which the units should be considered
Indexing
First indexing unit of the filing segment
Key unit
Card, Folder or slip of paper inserted temporarily in the files to replace a record that has been retrieved from the files
Out guide
A type of patient chart record keeping that uses a sheet at a prominent location in the chart to list vital identification data
Problem-oriented medical record (POMR)
Method of maintaining order in the files by separating active from inactive and closed files
Purging
Acronym for patient progress notes based on subjective impressions (S), objective clinical evidence (O), assessment or diagnosis (A), and plans for further studies (P)
SOAP/SOAPER
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
Source-orientated medical record (SOMR)
System to remind of action to be taken on a certain date.
Tickler file
Each part of a name, words, or numbers that will be indexed and coded for filing
Unit
(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
Chart notes/Progress notes
Specific symptom or problem for which the patient is seeing the provider today
Chief complaint (CC)
Medical reports that document the hospitalization history of a patient
Discharge summary (DS)
Patient medical record from a single medical practice, hospital, or pharmacy
Electronic Medical Record (EMR)
Viewing specimens with the naked eye
Gross examination
Government rules, regulations, and procedures resulting from legislation designed to protect the confidentiality of patient information
Health insurance portability and accountability act (HIPAA)
The chronological description of the development of the patient’s illness
History of the present illness (HPI)
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
Outsourcing
Medical report that chronicles the details of a surgical procedure
Operative report (OR)
Medical reports generated to describe the gross and microscopic examinations performed during a surgical procedure
Pathology report
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
Quality assurance (QA)
Inquires about the system directly related to the problems identified in the history of the present illness
Review of systems (ROS)
