Chapter Twenty-Three: The Medical Record, Documentation, and Filing Flashcards
audit
inspection
charting
process that lays out a chronological account of the patient reports, provider’s evaluation, prescribed treatment, and responses to the treatment as well as the need for further follow-up
chief complaint
noted in the patient’s medical record as the main reason for the patient’s visit
chief complaint, history, examination, details, drugs/dosages, assessment, and return visit
acronym that provides a structured charting method for data acquired during a routine health care visit; it encourages a more detailed account of the information obtained during the patient interview and examination
chronologic
the arrangement of events, dates, and so on in order of occurrence
documentation
refers to both the act of preparing and the evidence created when a health care professional records information regarding a patient during the course of assessment and treatment; can be handwritten or electronically
Electronic medical records (EMRs)
patient records in a digital format
ethnicity
demographic term that indicates what societal group a patient identifies with
history physical impression plan (HPIP)
a similar system to SOAP of recording medical information about patients is the history physical impression plan (HPIP) method
indexing
a system of cross-referencing information contained in office files so that the data may be searched using different characteristics as the query term; the second step in filing
interoperability
(Formerly known as Meaningful Use), under MIPS the focus shifted from meaningful use to interoperability and improving patient access to health information
meaningful use
with reference to health care records, this term is used by government agencies to refer to the way in which medical record information is employed in order to provide a means for improving patient care and patient outcomes through evaluating treatment patterns and verifying necessity of medical procedures performed; determines the way in which electronic health record (EHR) technologies must be implemented and used for a provider to be eligible for the EHR Incentive Programs and to qualify for incentive payments
Medicare Promoting Interoperability (PI) Program
(Formerly known as Meaningful Use), under MIPS the focus shifted from meaningful use to interoperability and improving patient access to health information
objective
(1) information or symptoms that can be observed such as vital signs, exam findings, laboratory results, special procedure findings, X-ray reports, diagnoses, prescribed treatments, progress notes, and diagnostic tests; (2) on a microscope, a lens or series of lenses
privacy officer
the person designated by a health care organization, whether hospital system or private practice, who handles and oversees the maintenance of protected health information
problem-oriented medical record (POMR)
a system of recordkeeping used to collect specific pieces of information regarding a patient during a health care visit, such as patient profile, chief complaint, review of systems, physical examination, laboratory reports, chronic problems, medication and preventive care lists, and patient education
progress notes
record of the continuing progress and treatment of a patient
property right
the entitlement to anything that is owned by a person or entity. Property is divided into two types: real property, which is any interest in land, real estate, growing plants or the improvements on it; and personal property, which is everything else
purge
(1) when referring to charts, to clean out; purge files of those patients who are no longer being seen by the provider(s); (2) to empty; to cleanse of impurities; clear
subjective
(1) when referring to charting, information is supplied by the patient and includes routine information about the patient, past personal and medical history, family history, and chief complaint; (2) relating to the person who is thinking, saying, or doing something; personal; of a disease symptom, felt by the individual but not perceptible to others
subjective objective assessment plan
one of the most widely used methods of charting, to collect patient visit information; appropriate for most types of patient encounters
tickler file
a chronologic file commonly used as a follow-up method for a particular date
