Information Management Flashcards
Computer
Electronic device that receives, manipulates, and stores data.
Computer Classification
According to size: Generally, larger computers have greater storage capacity and faster processing times.
- Supercomputer - Mainframe - Minicomputer - Microcomputer
Supercomputer
Large, complex computer system capable of performing rapid, complex functions, such as national defense and weather forecasting and research.
Mainframe
Large computer capable of handling hundreds of users.
Minicomputer
Medium-sized computer that can handle multiple users.
Microcomputer
Desktop personal computer (PC).
Hardware
Physical computer equipment.
Central processing unit (CPU)
Collection of three components that process data.
- Control Unit (CU) - Arithmetic logic unit (ALU) - Primary storage unit (PSU)
Control unit (CU)
It doesn’t perform the actual data processing, it supervises the data processing operations. The CU performs the following:
- Retrieving: obtains instructions from the primary storage unit. - Decoding: translate the instructions into language the computer understands. - Executing: carries out the instructions. - Storing: Results of the instructions are stored in the primary storage unit (PSU).
Control Unit- Retrieving
Retrieving:
- Obtains instructions from the primary storage unit.
Control Unit- Decoding
Decoding:
- Translate the instructions into language the computer understands.
Control Unit- Executing
Executing:
- Carries out the instructions.
Control Unit- Executing
Executing:
- Carries out the instructions.
Control Unit- Storing
Storing:
- Results of the instructions are stored in the primary storage unit (PSU).
Arithmetic Logic Unit (ALU)
Processes the data in two ways.
- Arithmetic operations - Logic operations
Arithmetic operations
Mathematical calculations involving addition, subtraction, multiplication and division.
Primary Storage Unit (PSU)
Main computer memory that stores data and program instructions.
- Random access memory (RAM) - Read only memory (ROM)
Primary Storage Unit (PSU)
Main computer memory that stores within the CPU that is lost once power is discontinued.
Random Access Memory (RAM)
Temporary memory within the CPU that is lost once power is discontinued.
Random Access Memory (RAM)
Temporary memory within the CPU that is lost once
Read Only Memory (ROM)
Permanent memory within the CPU installed by the manufacturer that allows the computer to carry out its operations.
Input devices
Allows for the input of data into a computer.
- Keyboard - Mouse - Trackball - Joystick - Digitalized tablet - Light pen (wand) - Scanners
Input devices-
Keyboard:
- Allows for the input of alphanumeric data.
Input devices- Keyboard
Keyboard:
- Allows for the input of alphanumeric data.
Input devices- Mouse
Mouse:
- Handheld device that, when moved across a flat surface, moves the cursor to any spot on the monitor screen.
Input devices- Trackball
Trackball:
- A ball embedded in the base when rolled, moves the cursor on the screen.
Input devices- Joystick
Joystick:
- A vertical stick embedded in a base that moves the cursor in the direction the stick is moved.
Input devices- Digitalized tablet
Digitalized tablet:
- A pressure sensitive pad that produces on the screen any outline drawn on the pad.
Input devices- Light pen (wand)
Light pen (wand):
- A pen that is sensitive to the light emanating from the screen. When placed close to the screen, it can control the cursor and activate various functions.Output devices
Allows for data to be displayed or recorded.
- Monitor - Printer - Plotter
Output devices
Allows for data to be displayed or recorded.
- Montior - Printer - Plotter
Output devices- Monitor
Monitor:
- Cathode ray tube (CRT) or screen that visually displays data.
Output devices- Printer
Printer:
- A device that records data on hard copy (paper).
Ports
Means of connecting peripheral to the CPU.
- Serial port - Parallel port.
Ports
Means of connecting peripheral to the CPU.
- Serial port - Parallel port.
Serial port
Sequentially transfers data on one piece at a time.
Parallel port
Transfers groups of data at a time.
Secondary storage
Due to the temporary nature of RAM in the primary storage unit, it is necessary to use secondary storage components to store data and programs.
- Hard disk - Floppy disk - Disk drive - Magnetic tape - Optical disks - Solid-state devices
Secondary storage- Hard disk
Hard disk:
- Internally contained magnetic disk for data and program storage.
Secondary storage- Hard disk
Hard disk:
- Internally contained magnetic disk for data and program storage.
Secondary storage- Floppy disk
Floppy disk:
- External magnetic disk, that, when inserted into a disk drive, can store and load data and programs.
Secondary storage- Disk drive
Disk drive:
- Electronic device that retrieves and stores data on a diskette.
Secondary storage- Magnetic tape
Magnetic tape:
- Magnetic cassette tape or reel used to store data and programs.
Secondary storage- Optical disks
Optical disks:
- DVD’s (digital Video Disks) and CD’s (Compact Disks). Data is stored on a metal surface that can be read by a laser.
Secondary storage- Solid-state device
Solid-state device:
- Small (size of a thumb or car key) removable storage/memory cards that have no moving parts. They plug into a USB port on the computer, and have various names depending on the manufacturer (e.g., flash drive, flash pen, thumb drive, key drive and mini-USB drive.
Software
A computer program that provides processing instructions to the computer.
- System software - Application software
Data Processing- Transforming data into a useful information
- Data: Raw information such as numbers and letters that the computer processes.
- Information: Processed data that can be used in a meaningful way.
Data Processing
- Transforming data into a useful information
- Memory
- Machine language
- Data processing cycle
Data Processing
Transforming data into useful information.
- Data: Raw information such as numbers and letters that the computer processes. - Information: Processed data that can be used in a meaningful way.
Data Processing- Memory-
“Bit”
Bit:
- Binary digit. Smallest piece of information processed by a computer. - When an electrical charge is absent, the bit is off and takes the binary value 0.
Data Processing- Memory
Memory:
- Bit - Byte - Kilobyte (K) - Megabyte (M)
Data Processing- Memory-
“Bit”
Bit:
- Binary digit. Smallest piece of information processed by a computer.
Data Processing- Memory-
“Byte”
Byte:
- An 8-bit unit. One byte of memory is required to represent a character.
Data Processing- Memory-
“Kilobyte”
Kilobyte:
- Represents 1024 bytes.
Data Processing- Memory-
“Megabyte”
Megabyte:
- Represents 1000 kilobytes.
Machine language
Binary computer coding system that represents each data character.
Machine language- ASCII
ASCII: American Standard Code for Information Interchange.
- A machine language used in many microcomputers.
Machine language- EBDIC
EBCDIC: Extended Binary Coded Decimal Intercharge Code.
- A machine language used by larger computers.
Data processing cycle
- Input: Data is entered into a computer via an input device.
- Processing: Manipulation of the data that has been inputted.
- Output: After the data is processed, resulting information can be accessed via an output device.
- Storage: Input or output data or information is stored on a storage medium such as a floppy disk .
Booting
Process of activating the input of the operating system into a main memory.
Program installation
Process of loading the software instructions onto the hard disk of the computer. Specific installation instruction are included with the software package.
Disk formatting
Process of organizing a blank disk into sectors so that it can store data.
Disk copy
Process of copying a file on a diskette or copying the contents of an entire diskette onto a second diskette, especially backup copies.
Configuration
Disk drive arrangement.
Bus
Any path that data travels inside the computer.
Buffer
Location for temporary data storage during computer processing.
Bus
Any path that data travels inside the computer.
Clipboard
A section of computer memory used to temporarily hold data that has been cut or copied for transfer to another document or location within a document.
Data compression
Program that forces data into less space on the storage medium.
Glidepad
Touch-sensitive pad for controlling cursor motion. Common on laptops.
Megahurtz MHz
1 million cycles per second.
Network
A set of computers that are permanently linked together.
Node
Each device connected to a network.
OCR software
Software that changes a scanned document from an image to editable text– commonly used for insurance claims.
Personal Data Assistant (PDA)
Small personal computer with limited capabilities.
Point size
Measures the height of letters where 1 point is 1/72 inch.
Query
A way to arrange records in a particular kind of order or to show only the records that match certain criteria.
Queue
The set of print jobs waiting to be done.
Server
A computer that handles network tasks.
Suite
A set of separate applications that are packaged together usually at a lower price than they would cost separately, e.g., Microsoft Office Suite.
Tower
Vertical case for a personal computer.
Word processing functions- Formatting
Formatting:
- Determines the physical layout of a document.
- Margins
- Tab set
- Line spacing
- Pitch
Word processing function- Formatting
“Pitch”
Pitch:
Sets the number of characters per inch of text.
- Pica: 10 characters per horizontal inch.
- Elite: 12 characters per horizontal inch.
Word processing functions- Formatting
“Widow/Orphans”
Eliminates a window or orphan.
- A widow is the last paragraph line appearing alone at the top of the page. - An orphan is the first paragraph line appearing alone at the bottom of a page.
Word processing functions- Formatting
“Retrieval”
Acquiring from storage, data, or information that has been saved on a disk.
Word processing functions- Formatting
“Justification”
Determines the alignment of text relative to the left or right margin.
Word processing functions- Formatting
“Header/Footer”
Prints identical information at the top or bottom of each page.
Word processing functions- Formatting
“Pagination”
Positions and prints page numbers.
Word processing- Editing
“Block”
Using the cursor, text can be highlighted for manipulation.
Word processing functions- Window
An application that allows more than one application to be operational at one time.
Word processing- Sort
Organize a list alphabetically or numerically in ascending or descending order.
Word processing functions- Desktop publishing
Document presentation tool that permits the production of professional documents containing both text and graphics.
Spreadsheets- Numbers productivity tool
- Software programs that permit rapid calculations applied to a table of numerical data.
Sort
Organize a list alphabetically or numerically in ascending or descending order.
Desktop publishing
Document presentation tool that permits the production of professional documents containing both text and graphics.
Spreadsheets- Numbers productivity tool
- Software programs that permit rapid calculations applied to a table of numerical data.
- Worksheet: Working document that contains empty rows and columns for the input of data that can be numerically manipulated.
Spreadsheet- Worksheet
Worksheet: Working document that contains empty rows and columns for the input of data that can be numerically manipulated.
- Columns headings are alphabetical. - Row headings are numerical. - Cell: intersection of a row and column; e.g., cell A1 represents the space occupied at column A, row 1.
Spreadsheet- Data forms
the following types of data can be entered in a cell.
- Labels: Alphanumeric characters usually used as headings to identify the row or column. - Numerical data to which calculations can be applied. - Formulas: Provide instructions for performing a mathematical calculation on data entered in other cells.
Spreadsheet- Formula symbols
- Addition +
- Subtraction -
- Multiplication X
- Division /
- Exponents ^
Spreadsheet- Order of operations
When entering a formula, certain mathematical tasks will be carried out in a specified order. Calculations will be performed from left to right with parentheses first, then exponents, multiplication and division, and finally addition and subtraction.
Spreadsheet- Special functions
- @SUM: Will add a group of values.
- @AVG: Will average a group of values.
- @SQR: will determine the square root of a value.
Spreadsheet- Range
A designated group of cell sbeing affected by a calculation or task; e.g., (A1..C5) indicates that the task at hand should be applied to cells A1, A2, A3, through A15, B1, B2, through B15, C1, C2, C4, and C5 only.
Data hierarchy- Records & Files
- Fields: Basic piece of data such as a name, address, or course grade; usually arranged in columns.
- Records: Collection of related fields, usually arranged in rows. Each record within a file will have the same collection of fields.
- Fields: Collection of related records.
Database- Data management tool
Software programs that facilitate the collection of data files that can be accessed, manipulated, rearranged, sorted and categorized to meet users information needs.
Database- Data hierarchy
- Fields: Basic piece of data such as a name, address, or course grade; usually arranged in columns.
- Alphanumeric: Data using any combination of letters, numbers, or symbols.
- Numeric: Numerical data used as codes or for calculations, or to express quantity.
- Logical: Data having one of two possible conditions; yes/no, male/female, true/false, etc.
Data hierarchy- Records & Files
- Records: Collection of related fields, usually arranged in rows. Each record within a file will have the same collection of fields.
- Fields: Collection of related records.
Database- Entry operations
“Additions”
Adding a field, record, or file to a database.
- Ascending: Adding data at the end of a data set. - Inserting: Adding data between data sets. - Deletion: Removing a field, record, or file from a database. - Modification: changing an existing field, record or file.
Database- Detail reports
Detail reports:
- Reports that list the records in each file.
Medical Practice Software
- Handles appointment scheduling, billing, and collection.
- The data contains demographic, financial and insurance information.
- Each new patient’s information is added to the database.
- Codes the service to system can generate a claim for a third party payer or for the patient.
- Can fun financial reports.
- May include a code-checker to prevent improper coded claims.
Database report- Exceptional report
Exceptional report:
- Reports that identify fields or records that have a unique characteristic; commonly describes data that falls outside the norm or predetermined data set.
Database- Det ail reports
Detail reports:
- Reports that list the records in each file.
Medical Practice Software
- Handles appointment scheduling, billing, and collection.
- The data contains demographic, financial and insurance information.
- Each new patient’s information is added to the database.
- Codes the service to system can generate a claim for a third party payer or for the patient.
- Can fun financial reports.
- May include a code-checker to prevent improper coded claims.
Medical Practice Software- E-prescribe
E-prescribe:
- Provides reminders and alerts, and promotes compliance with guidelines and formularies.
Medical Practice Software- Planning and implementation of information technology (IT)
- considered the future of medical decision-making.
- Information offers tools, not solutions.
- The success or failure of IT applications is related to change management.
- Treat IT decision as cyclical
- Educate and train your staff on IT
- IT application are dependent on people.
- Don’t try to do everything yourself.
Medical Practice Software- Consideration
- Needs and wants.
- Time frame for the IT applications.
- Who will be responsible?
- What process will you use to evaluate your options and make a decision?
- How will you evaluate the results of your purchase.
Medical Practice Software- Steps
- HIPAA Security Rule Compliance.
- Set goals and priorities.
- Create a task force.
- Develop a practice profile.
- Identify and solicit vendors.
- Compare rank vendors responses.
- Make site visits and check references.
- Select the vendors and sign agreements.
- Develop an implementation plan.
- Evaluate the results.
- Start again.
Medical Practice Software- Keys to success
- Identify a champion who is able and willing to coach others through the transition process.
- Enlist the commitment of all physicians in the practice.
- Plan the timing to suit practice needs.
- Retain control of training and transition.
- Purchase an adequate level of support.
Data Communications
- Connectivity tool
- Transfer of data from one point to another such as between computers in a room, or over long distances.
Data Transmissions
- Movement of data across communication lines.
- Serial transmission
- Parallel transmission
- Asynchronous
- Synchronous transmission
- Simplex
- Half duplex
- Full duplex
Serial transmission
Data is transmitted one bit at a time sequentially.
Parallel transmission
All bits in a byte are transmitted simultaneously.
Asynchronous
Bytes are transmitted one at a time.
Synchronous
Bytes are transmitted in groups.
Simplex
Data is transmitted in one direction only.
Half duplex
Data can be transmitted to and from the point of origin, but only one direction at a time.
Full duplex
Data can be transmitted in both directions simultaneously.
Modem
Hardware component known as a modulator-demodulater that connects computers to communication lines.
Networks
Collection of terminals, computers and other equipment that uses communication channels to share data, information, hardware, and software.
- Local Area Network (LAN) - Metropolitan Area Network (MAN) - Wide Area Network (WAN)
Integrated software
- Combination productivity tool.
- Software package that combines applications such as word processing, spreadsheet, database, desktop publishing, and data communications programs to offer a powerful and flexible data processing tool.
MAN
Metropolitan Area Network:
- Privately owned communication network that covers a large citywide operation.
WAN
Wide Area Network:
- Communication network that are privately or publicly owned covering a wide geographic area through the use of telephone lines, microwaves, and satellites.
Integrated software
Combination productivity too. Software package that combines applications such as word processing, spreadsheet, database, desktop publishing, and data communications programs to offer a powerful and flexible data processing tool.
Computer crime- Salami shaving
A form of computer embezzlement diverts small amounts of money from private accounts into one’s account.
Computer crime- Software piracy
Illegally acquiring and using computer software (bootleg software) in violation of copyright laws. Site licensing generally must be purchased to copy software for multiple users in an organization.
Computer crime- Computer embezzlement
Using computer technology to illegally divert funds.
Salami shaving
A form of computer embezzlement diverts small amounts of money from private accounts into one’s account.
Computer crime- Time bombs
Computer programs that are designed to erase files or compromise data.
Computer crime- Data diddling
Changing data for one’s own benefit; e.g., credit reports.
Computer crime- Trojan horse/trap door
A computer program designed to acquire access codes and passwords for illegal entry into a computer system.
Computer crime- Computer virus
A program created by another computer user that adversely affects the integrity of data or proper functioning of identity theft.
Electronic Communications Privacy Act of 1986
Protects against illegal interception of data communications.
Medical Records- Electronic Health Record (EHR)
- Complex system of coordinated hardware, software, people, policies, and processes in support of patient care.
- The ideal EHR system will capture data from multiple sources and used at a point-of-care (POC) to support clinical decision-making.
A fully realized EHR system will provide
- Seamless information interchange among providers at all levels of the health care continuum.
- Support for fully integrated evidence-based medicine.
- Embedded medical terminology to assist with documentation.
EHR Benefits
- Provide documentation of clinical findings and procedures.
- Active reminders for medication administration.
- Protocols for medical procedures.
- Combined scheduling, registration, and billing system.
- Data and information can be exchanged with other providers and system.
- CCR: Continuity of Care Records: Standards content physicians agree should be in a referral.
CCR
Continuity Of Records
EHR
Electronic Health Records
EHR Technology-
- Databases
- Data exchange
- Images
- Workflow systems
- Data retrieval
- Data capture technology
- System communications and networks
- Storage technology
- Workstation
EHR Technology- Databases
Databases:
- Organized collection of data in standardized format
EHR Technology- Data capture technology
Data capture technology:
- Human-computer interfaces; e.g. templates, macros, speech/handwriting recognition, handheld/wireless devices, patient devices, etc.
EHR Technology- Images
Images:
- Electronically store and view documents and clinical images.
EHR Technology- Workflow systems
Workflow systems:
- Any work process that must be handled by more than one person. Allowing access to the same information by multiple users.
EHR Technology- Data retrieval technology
Data retrieval technology:
- Viewing data in a flexible format.
EHR Technology- Data capture technology
Data capture technology:
- Human-computer interfaces; e.g. templates, macros, speech/hand-writing recognition, handheld/wireless devices, patient devices, etc.
EHR Technology- System communication and network
System communication and network:
- Hardware and architecture, LAN, WLAN and WANs.
EHR Technology- Storage technology
Storage technology:
- Capable of archiving enormous amounts of data that can be retrieved in real-time.
Health Care Data Sets- Data set
Data set:
- List of recommended data elements having uniform definitions.
Health Care Data Sets- Common Data Sets
Common Data Sets:
- Uniform Hospital Discharge Data Set (UHDDS): Inpatient hospital care. - Uniform Ambulatory Care Data Set (UACDS): Care provided to patient who return home on day of service. - Minimum Data Set for Long-Term Care (MDS): Nursing home residents. - Outcome and Assessment Information Set (OASIS): Medicine beneficiaries receiving services from a home health agency. - Data Elements for Emergency Department Systems (DEEDS) - Essential Medical Data Set (EMDS): complements DEEDS; concise medical history data set for each patient. - Health Plan Employer Data and Information Set (HEDIS): - Provides consumer with information needed to compare the performance of managed care plans.
Health Care Data Sets- Common Data Sets
“Uniform Hospital Discharge Data Set (UHDDS)”
Uniform Hospital Discharge Data Set (UHDDS):
- Inpatient hospital care.
Health Care Data Sets- Information
Information:
- Data has been collected, combined, analyzed, interpreted, and/or converted into a form that is meaningful.
Health Care Data Sets- Data set
Data set:
- List of recommended data elements having uniform definitions.
Health Care Data Sets- Common Data Sets
Common Data Sets:
- Uniform Hospital Discharge Data Set (UHDDS): Inpatient hospital care. - Uniform Ambulatory Care Data Set (UACDS): Care provided to patient who return home on day of service. - Minimum Data Set for Long-Term Care (MDS): Nursing home residents. - Outcome and Assessment Information Set (OASIS): Medicine beneficiaries receiving services from a home health agency. - Data Elements for Emergency Department Systems (DEEDS) - Essential Medical Data Set (EMDS): complements DEEDS; concise medical history data set for each patient. - Health Plan Employer Data and Information Set (HEDIS): - Provides consumer with information needed to compare the performance of managed care plans.
Health Care Data Sets- Common Data Sets
“Uniform Hospital Discharge Data Set (UHDDS)”
Uniform Hospital Discharge Data Set (UHDDS):
- Inpatient hospital care.
Health Care Data Sets- Common Data Sets
“Uniform Ambulatory Care Data Set (UACDS)”
Uniform Ambulatory Care Data Set:
- Care provided to patient who return home on day of service.
Health Care Data Sets- Common Data Sets
“Minimum Data Set for Long-term Care”
Minimum Data Set for Long-Term Care:
- Nursing home residents.
Health Care Data Sets- Common Data Sets “Outcome and Assessment Information Set (OASIS)
Outcome and Assessment Information Set (OASIS):
- Medicare beneficiaries receiving services from a home health agency.
Health Care Data Sets- Common Data Sets “Data Elements for Emergency Department Systems (DEEDS)”
Data Elements for Emergency Department Systems (DEEDS):
- Essential Medical Data Set (EMDS): Complements DEEDS; concise medical history data set for each patient.
Health Care Data Sets- Common Data Sets “Health Plan Employer Data and Information Set (HEDIS)”
Health Plan Employer Data and Information Set (HEDIS):
- Provides consumers with information needed to compare the performance of managed care plans.
Records Management-
System of classifying, arranging and storing documents in an orderly, efficient\, and easily accessible manner.
Records Management- Out guide
Out guide:
- A guide used to replace a chart that has been temporarily removed from the cabinet, identifying the location or person in possession of the record.
Records Management- Common storage media
- Hardcopy
- Microfiche/microfilm
- Computer
Records Management- Equipment and supplies
Storage cabinet:
- Vertical: File cabinet style
- Lateral: Chest of drawers style
- Shelf:
1. Open or closed
2. Stationary or pullout shelves
Records Management- Guides
- Out guide: A guide used to replace a chart that has been temporarily removed from the cabinet, identifying the location or person in possession of the record.
- Out folder: A folder that serves as an out guide but can hold patients documents temporarily until the medical record is returned.
Records Management- Out guide
Out guide:
- A guide used to replace a chart that has been temporarily removed from the cabinet, identifying the location or person in possession of the record.
Records Management- Out folder
Out folder:
- A folder that serves as an out guide but can hold patients documents temporarily until the medical record is returned.
Records Management- Folders
Folders:
- Cardboard or plastic holders that contain a file’s documents. Folders are often equipped with tabs to aid in the identification of their concerns.
Records Management- Labels
Labels:
- Small stickers affixed to folders, drawers, and shelves to identify their contents.
Records Management- Alphabetical indexing rules
A person’s name is indexed with the surname as unit 1, the given name as unit 2, and the middle name as unit 3. A fourth unit, usually date of birth is used fro identical names.
Records Management- Alphabetical indexing rules
Initials comes before complete names starting with the same letter.
Records Management- Alphabetical indexing rules
Units having no names come before those that do (nothing come before something).
- Able W. A. - Able Warren Seth
Records Management- Alphabetical indexing rules
A hyphenated name is considered a single unit, e.g. Michael-Smith is indexed Michaelsmith. And the hyphen is disregarded unless it is a business name; in this case, they are placed in separate units at the hyphen.
Records Management- Alphabetical indexing rules
Apostrophes in a name are disregarded, e.g. O’brian is indexed as Obrian.
Records Management- Numerical filing
- Each patient is assigned a number that is identified on their medical chart.
- Each patient’s number is cross-referenced with the patient’s name and filed alphabetically.
- Commonly used in hospitals, group practices, and large clinics.
Records Management- Alphabetical indexing rules
Abbreviations are indexed as if written in full., e.g. Wm is indexed William.
Records Management- Alphabetical indexing rules
Numbers as part of a name are indexed as if written out. e.g., 4th is indexed fourth.
Records Management- Alphabetical indexing rules
Titles, degrees, and terms for seniority usually are not condiere4d in filing but may be indexed last, or may be placed in parenthesis at the end of the name for identification purposes, e.g., Dr., Pastor, Professor, Ph.D., M.S., B.S., A.S., Sr., Jr., I., II., III.
Records Management- Numerical filing
- Each patient is assigned a number that is identified on their medical chart.
- Each patient’s number is cross-referenced with the patient’s name and filed alphabetically.
- Commonly used in hospitals, group practices, and large clinics.
Records Management- Consecutive numerical system
Each patient is assigned a number in the order of their first visit.
Records Management- Terminal digit system
- Patients are assigned consecutive numbers as they visit the clinic.
- The numbers are separated into groups of two or three.
- Individual #
- Secondary #
- Primary #
Records Management- Terminal digit filing
Index by primary number in ascending order. Then by secondary number in ascending order. Finally by to individual number in ascending order.
Records Management- Subject filing
Documents are indexed according to geographic location.
Records Management- Geographic filing
Documents are indexed according to geographic location.
Records Management- Phonetic filing
Records are filed according to the sound of names rather than on spelling. Consonant sounds are assigned a code number and filed accordingly.
Records Management- Electronic filing
- Bar codes: Medical records may be labeled with bar codes that can be read and tracked by computer software.
- Scanners: Scanning devices may be used to scan and index insurance documents and the like.
- Databases: Electronic files that can be accessed according to some search criteria.
Records Management- Color coding
- Colored tabs may be employed to represent information about a chart or a patient at a glance.
- Most color coding system are used on letters of the patient’s surname to identify misfiled charts.
Records Management- Tickler file
A general filing system that organizes items chronologically for follow-up such as appointments accounts payable due dates, or insurance tracking.
Mail Processing- Quality control
Scale can be quality controlled by verifying that nine pennies equal 1oz.
Mail Processing- Postage meter
Machine used to print prepaid postage directly on envelopes or adhesive strips. May be used for any class of mail.
Mail Processing- Rubber stamps
To indicate date of receipt and to place restrictive endorsement of checks.
Mail Processing- Tracing mail
Mail that has not reached its destination can be traced by completing a postal form.
Mail Processing- Recalling mail
If mail has been sent in error, it may be returned if the mail has not been delivered to the recipient.
Mail Processing- Incoming mail
- Mail inadvertently opened should be resealed with tape with a notation indicating it was opened in error.
- All checks received should be immediately stamped with a restrictive endorsement.
Mail Processing- Fourth class
Parcel post. Delivery of packages and printed materials weighing 1 to 70lb within specified physical dimensions (108 inches). postage depends on weight and destination.
Mail Processing- Mixed class
Delivery of a letter sent with a parcel.
Mail Processing- Special fourth class
Delivery of books and manuscripts that have a minimum of 24 pages of which at least 22 must be text or illustrations without any form of advertising.
Writing Mechanics- Verb
Verb:
- A word that describes an action, or limits a noun– tells you something about the noun.
Writing Mechanics- Adjective
Adjectives
- A word that describes or limits a noun– tells you something about the noun.
Mail Processing- Mail log
An incoming and outgoing log may be established to record daily mail activity.
Writing Mechanics- Noun
Noun:
- A word that names a person, place, thing, idea, living creatures, quality or action.
Writing Mechanics- Verb
A word that describes an action, or limits a noun– tells you something about the noun.
Writing Mechanics- Adjective
Adjectives:
Writing Mechanics- Adverb
Adverb:
- A word that describes, limits, or qualifies a verb, adjective, or other adverb– tells when, where, why, or how something was done.
Writing Mechanics- Pronoun
Pronoun:
- Word that replaces a noun to avoid repeating the noun, e.g., I, you, he, she, it, we, they.
Writing Mechanics- Conjunction
Conjunction:
- Joins two words, phrase, or clauses together, e.g., for, and, not, but, or, yet, so.
Writing Mechanics- Preposition
Preposition:
- Joins a noun to some other part of the sentence– often describes the position, direction, location, time, or place of a noun.
Writing Mechanics- Independent clause
Independent clause:
- The basic unit of a sentence. The subject and verb must form a complete thought, e.g., the medical assistant collected some blood.
Writing Mechanics- Article
Article:
- A word that introduces a noun, e.g., a, an, the.
Writing Mechanics- Phrase
Phrase:
- A group of words that does not contain a subject (includes a noun) or a verb that complement each other, e.g., the medical assistant.
Writing Mechanics- Clause
Clause:
- A group of words that contains both a subject and a verb that complements each other, e.g., the medical assistant collected.
Writing Mechanics- Independent clause
Independent clause:
- The basic unit of a sentence. The subject and verb must form a complete thought, e.g., the medical assistant collected some blood.
Writing Mechanics- Dependent clause
Dependent clause:
- Contains a subject and verb, but the clause cannot be identified by the use of dependent clause markers, e.g., because, since, when, while, until, if, as, though, although, unless, after, before, once, whether.
Writing Mechanics- Essential clause or phrase
Essential clause or phrase:
- Modifies a noun and is critical to the meaning of the sentence.
Writing Mechanics- Nonessential clause or phrase
Nonessential or phrase:
- Adds extra information to a sentence. This information can be eliminated from the sentence without jeopardizing the meaning of the sentence.
Writing Mechanics- Sentence
Sentence:
- Has at least an independent clause– a subject and verb that expresses a complete thought.
Writing Mechanics- Simple sentences
Simple sentences:
- Includes one independent clause– a sentence that can stand alone, e.g., The medical assistant called in late.
Writing Mechanics- Apostrophe ( ‘ )
Apostrophe”
- Indicates the possessive of nouns, e.g., the girl's mother, Degas's art, birds' migration. - Marks the omission of letters in contracted words, e.g., didn't, they're, he'd.
Writing Mechanics- Compound sentence
Compound sentence:
- On that contains two independent clauses joined by a coordinating conjunction, e.g., The medical assistant called in late because she was delayed by traffic.
Writing Mechanics- Complex sentence
Complex sentence:
- Includes an independent clause and one or more dependent clauses– cannot stand alone as a sentence, but modifies or enhances the independent clause, e.g., the medical assistant, who is not an early riser, called in late.
Writing Mechanics- Compound complex sentence
Compound complex sentence:
- Includes tow or more independent clauses and one or more dependent clauses, e.g., The medical assistant, who is not an early riser, called in late because she was delayed by traffic.
Writing Mechanics- Dash -
Dash:
- Marks and abrupt change in the sentence structure, e.g.,Dr. Adams just arrived to the OR-- what do you make of his choice of the tie. - Replaces commas or parentheses to emphasize a parenthetical phrase, e.g., She had the facts right--the glucose was high and the WBC count was low--however, she dr3w the wrong collection. - Introduces defining phrases, e.g., A type I error--alpha.
Writing Mechanics- Ellipsis (…)
Ellipsis:
- Indicates the omission of one or more words within a quotation, e.g., "Four score and seven..." - Indicates faltering speech or an unfinished sentence, e.g., no, no, please don't..ugh.
Writing Mechanics- Brackets [ ]
Brackets:
- Encloses editorial comments within quoted material, e.g., He piqued [sic] outside the window. - Encloses insertions that supply missing letters, e.g., She decide[d] otherwise. - To serve as parentheses within parentheses, e.g., the Greek letter m (u [mu]).
Writing Mechanics- Colon :
Colon ( : )
- Introduces an amplifying words or phrase, e.g., There is only person who can do the job: Patrick. - Introduces lengthy quoted material set off from the rest of the text by indentation without quotation marks,
Writing Mechanics- Comma ,
Comma:
- Separates a series of three or more items, e.g., She passed the forceps, scalpel, and gauze in that order. - Separates state from city and the remaining sentence, e.g., She went to Vincennes, Indianan, to go to school.
Writing Mechanics- Dash -
Dash:
- Marks and abrupt change in the sentence structure, e.g.,Dr. Adams just arrived to the OR-- what do you make of his choice of the tie. - Replaces commas or parentheses to emphasize a parenthetical phrase, e.g., She had the facts right--the glucose was high and the WBC count was low--however, she dr3w the wrong collection. - Introduces defining phrases, e.g., A type I error--alpha.
Writing Mechanics- Ellipsis (…)
Ellipsis:
- Indicates the omission of one or more words within a quotation, e.g., "Four score and seven..." - Indicates faltering speech or an unfinished sentence, e.g., no, no, please don't..ugh.
Writing Mechanics- Quotation marks double (“ “)
Quotation marks double:
- Encloses direct quotation but no indirect quotation, e.g., “The treatment is complete,” he said. He said the treatment was complete.
Writing Mechanics- Hyphen (-)
Hyphen:
- Links elements in compound words, e.g., post-recovery, middle-of-the-road.
Writing Mechanics- Parenthesis
Encloses phrases that provide illuminating information, e.g., Nurse Jones (an alumnus) gave the commencement address.
Writing Mechanics- Period
Period:
- Marks the end of a sentence, e.g., Every day in every way, I am getting better and better. - Periods are placed inside quotations marks. - Periods are placed outside the parenthesis if the parenthetical sentence is part of a larger sentence. They are placed inside the parentheses if not part of of another sentence. - Use it to end a rhetorical question.
Writing Mechanics- Question mark
Question mark:
- Ends a direct question, e.g., When will the physician arrive. - Indicates uncertainly about a fact.
Writing Mechanics- Quotation marks double
Quotation marks double:
- Encloses direct quotation but no indirect quotation, e.g., “The treatment is complete,” he said. He said the treatment was complete.
Writing Mechanics- Quotation marks, single
Encloses quoted material:
- Encloses quoted material within quoted material, e.g., She said, “I distinctly heard the student ask, ‘Will this be testable?’”
Letters structure- Closing
Closing:
- Complimentary close: Placed two lines below the line of the body.
- Formal: Truly yours and Very truly yours.
- Common: Sincerely and Sincerely yours.
- Mixed punctuation: Comma follow the complimentary close.
- Open punctuation: No terminal punctuation.
Writing Mechanics- Grammar in brief
The number of the subject should match that of the verb: If the noun is singular so should the verb; if the noun is plural the verb should is plural.
Letters structure- Heading
Heading:
- Usually composed of preprinted letterhead within the upper 2 inches of the page. - Dateline: Date of correspondence would be placed at least three lines below the letterhead or somewhere between lines 12 and 15.
Letters structure- Opening
Opening:
- Inside address: Placed four lines below the dateline.
- Attention line: Optional; placed two lines below the inside address. Directs the letter to a particular person or department when the letter is addressed to an organization.
- Salutation line: Optional; The opening greeting; placed two lines below attention line or inside address as appropriate.
- Subject line: Optional; placed two lines below the salutation. Indicates what the letter is about.
Letters structure- Body
Body:
- Contains the message; each line is single-spaced. - Paragraphs are double-spaced.
Letters structure- Closing
Closing:
- Complimentary close: Placed two lines below the line of the body.
- Formal: Truly yours and Very truly yours.
- Common: Sincerely and Sincerely yours.
- Mixed punctuation: Comma follow the complimentary close.
- Open punctuation: No terminal punctuation.
Letters structure- Signature line
Signature line:
- Placed four to five lines below the complimentary close.
Letters structure- Reference notation
Reference notation:
- Placed two lines below the signature.
Letters structure- Enclosure notation
Enclosure notation:
- Placed one or two lines below the reference notation.
Letters structure- Copy notation
Copy notation:
- Placed on or two lines below enclosure notation. - bc: Blind copy. Indicates a copy has been sent to a third party without the recipient's knowledge.
Letter styles- Full block
Full block:
- All lines begin flush at the left margin.
Letter styles- Modified block
Modified block:
- All lines begin flush at the left margin except the dateline and complimentary close, which begin at the center of the page.
Letter styles- Semiblock
Semiblock:
- Same as modified block except the beginning of each paragraph is indented five spaces.
Letter styles- Hanging identification
Hanging identification:
- Same as modified block except all lines of each paragraph are indented five spaces except the first line of each paragraph.
Letter styles- Simplified
Simplified:
- Same as full block except there is no salutation or complimentary close.
Margins
Margins: Free space along the four edges of the page.
- Short letter (less than 100 words): use 2 inch margins. - Medium letter (100 - 200 words): use 1.5inch margins. - Long letter (more than 200 words): use 1 inch margins
Multiple pages
- Type the recipient’s name seven lines from the top edge of the page.
- Type the page number one line below the recipients name.
- Type the date one line below the page number.
Example:
Name
Page number
Date
Spacing
- Six lines (7 returns) equal 1 inch.
- Pitch: Number of characters per inch of horizontal document space.
- Pica: 10 character per inch
- Elite: 12 character per inch
Envelopes
Common size:
- # 63/4: 61/2 inch x 35/8 inch - # 10: 91/2 inch x 41/8 inch
Return address- Senders address
- Placed three lines from top edge and five spaces from the left edge.
- Use all capital letters without punctuation.
Recipient’s address
- # 6 3/4: Two inches from top edge, and 2.5 inches from left edge.
- # 10: Two inches from top edge, and 4 inches from left margin.
- Leave a bottom margin of at least 5/8 inch.
Memoranda (memorandum)
- Written communication among workers within an office or organization.
- The message should begin three lines below the last line of the guide words.
Reference notation
- Identifies the transcriber’s initials.
- Placed two lines below the last line of the message.
Copy notation
- Indicates a copy of the memo that was provided to a third party.
- placed two lines below last lines of message or reference notation.
Multiple pages
- Type the subject line seven lines from the top edge of the page.
- Type the page number one line below the subject line.
- Type the date one line below the page number.
Manuscripts
- A written document that is submitted for publication.
- Different professional organizations, e.g., American Medical Assiciation (AMA) or American Psychological Association (APA), employ different standard formats for manuscript preparation and submission.
Manuscripts- Title page
Title page:
- Identifies the title or main theme of the manuscript. - The title, names of the authors, and their credential are usually centered vertically and horizontally.
Billing Statements- Acknowledgments
- Identifies those who have provided assistance on the research or preparation of the manuscript.
- Usually placed at the bottom of the or a separate page following the title page.
Manuscripts- Abstract
Abstract:
- Summary of the manuscript in 100 to 200 words. - Usually placed at the bottom half of the title page, or at the beginning of the text.
Manuscripts- text
Text:
- Title is typed in all capital, 13 lines from the top page. - The body of the text begins three lines below the title. - The text is usually double spaced.
Manuscripts- References
References:
- Identifying your published work of others in the text. - The references would then be listed numerically at the end of the manuscript. - References may also be cited using the author's last name, year of publication, and page numbers in parenthesis. The references would then be listed alphabetically by author at the end if the manuscript.
Example:
(Cody, 2010, p.45).
Footnotes:
- Cites references or other explanation information near the bottom of the page of which the referenced materialism printed rather than at the end of the manuscript.
Manuscripts- Footnotes
Manuscripts- Bibliography
Bibliography: List of source material or references used in preparing a written work.
- Articles: Author, “title,” journal, date, publication volume and number, pages.
- Example:
Cody, J.P., “Measuring Your Study Skills,” The Professional Medical Assistant, July/August, 1992, 35:4, pp.13-17.
- Texts: Author, title, publisher, year, pages.
- Example:
Cody, J.P., The CMA Review Manual, Delmar Cengage Learning, New York, 2005, p. 22.
Manuscripts- Illustrations
Illustrations:
- Placed on separate sheets and assigned consecutive figure numbers.
Manuscripts- Tables
Tables:
- Placed on separate sheet and assigned consecutive table numbers.
Manuscripts- Reprints
Reprints:
- Copies of a published article in pamphlet form to be given to interested colleagues.
Curriculum Vitae (CV)
- Latin for “Study of Life”.
- CVs area type of resume for selected professionals such as other healthcare providers and academicians, especially with a doctorate degrees.
Curriculum Vitae (CV) heading- Identifying information
Identifying information:
- Name, address, phone number
Curriculum Vitae (CV) heading- Family information
Family information:
- Although less common today, may identify name of spouse (including years of marriage) and names and ages of children.
Curriculum Vitae (CV) heading- Education
Education:
- Highest degree first. Degree, major, college, year of graduation.
Curriculum Vitae (CV) heading- Internship/residences
Internship/residences:
- For physicians and other health professional– specialty, sponsoring organization, and dates.
Curriculum Vitae (CV) heading- Licenses and certifications
Licenses and certifications:
- Name of license, number, and expiration date.
Curriculum Vitae (CV) heading- Experience
Experience:
- Professional positions held in reverse chronological order.
Curriculum Vitae (CV) heading- Memberships
Memberships:
- Include professional membership level, and service posts, e.g., president, treasurer, secretary, etc.
Curriculum Vitae (CV) heading- community service
Community service:
- Work performed with community and nonprofit organization, as well as service on boards and advisory committee.
Curriculum Vitae (CV) heading- Research activity
Research activity:
- Briefly describe past and current research work.
Curriculum Vitae (CV) heading- Publications
Publications:
- Published articles and books, as weeks as unpublished manuscripts.
Curriculum Vitae (CV) heading- Presentations
Presentations:
- Speeches or papers given to seminars or conferences; other speaking engagements, panel discussion, and the like. Note title, place and date.
Curriculum Vitae (CV) heading- Awards and honors
Awards and honors:
- Identify instances and tokens of special recognition.
Curriculum Vitae (CV) heading- Personal interests and hobbies
Personal interests and hobbies:
- Although less common today, this may be included as well.
Medical transcription
- Organizations that engages in medical transcription adhere to publish transcription formats and styles, or develop and document their own.
- Regardless of the format and style adopted, appearance, clarity, and legibility are the man consideration.
Medical transcription- Document title
Document title:
- Centered in all capital letters in the first line. Underscoring optional.
Medical transcription- Identifying information
Identifying information:
- Patient's name, record number, providers name, date of admission, and other similar information is typed at the left margin as header titles in capital and boldface lowercase letters, followed by a colon. - Each header title is double-spaced. - Identifying information is 2 spaces after the colon.
Medical transcription- Major headings
Major headings:
- Typed in all capital letters followed by a colon whether indicated or not. Underscoring, boldfacing, or typing on a separate line is optional.
Medical transcription- Secondary subheadings
Secondary subheadings:
- Typed in all capital letters followed by a colon and two spaces and inserted as dictated. Placement on a separate line is optional.
Medical transcription- Tertiary subheadings
Tertiary subheadings:
- Typed in capital and lowercase followed by a colon and two spaces. They are typed only if dictated within the narrative following the secondary subheading.
