Term
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Definition
observations and data are categorize according to their source
filed in reverse chronological order
information is filed in separate sections (lab reports section, xray report section etc) |
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Term
| Problemoreiented medical record (POMR) |
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Definition
| data organized acording to patients condition or disease; divided into database, problem list, plan, and progress notes |
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Term
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Definition
| for POMR; includes cheif complaint, present illness, physical examination findings, and lab results, each condition has its own page |
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Term
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Definition
| numbered and titled list of every patient complaint; may include physical, psychological, and social problems related to the patient's condition |
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Term
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Definition
| diagnostic and treatment decisions for the condition; each plan is titled and numbered |
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Term
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Definition
| structured notes that correspond to each problem number; uses the acronym SOAP |
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Term
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Definition
| subjective data: signs, symptoms, and feelings that the patient describes in their own words |
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Term
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Definition
| objective data: clinical evidence that the health care provider determines |
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Term
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Definition
| assessment = S+O describes the physical impression and finally diagnosis |
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Term
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Definition
| plan = S+O+A: action needed to solve the problem; may include treatment, medications, consultations, and surgery |
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Term
| what color ink may be used in medical charts? |
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Definition
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Term
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Definition
corrections are made using the SLIDE rule
SL = single line through error
I = initial of person correcting error
D = date and correct the error
E = write the word error |
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Term
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Definition
1. Current
2. Complete
3. Concise
4. Correct
5. Confidential
6. Clean |
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Term
| Who does the chart belong to? |
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Definition
| the health care provider or clinic |
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Term
| Who owns the information on the chart? |
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Definition
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Term
| Doctrine of professional discretion |
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Definition
| records can be withheld from a patient if the information can reasonable be expected to cause harm to the patient |
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Term
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Definition
| patients that have been seen within past 2-5 years |
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Term
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Definition
| records of patients not seen within a time frame specified by practice - usually stored in closed storage facility on or off site |
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Term
| Medical records may be destroyed by? |
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Definition
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Term
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Definition
| guide used to replace a file taken from the cabinet; enables technician to replace the file in the proper place whne ready |
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Term
| Alphabetical Filing Method |
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Definition
filed left to right by surname (unit 1), first name (unit 2), middle name (unit 3)
initials ar filed before complete names starting with same letter
units having no name filed before those that do (nothing before something)
Hyphenated name is a single unit unless business name then each name is seperate
Apostophes are ignored
Abbreviations are filed as if the whole word was spelled out
Numbers in a name are filed as if they were written out
titles and degrees are indexed last
with two identical names, they are filed by address |
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Term
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Definition
used when each patient is assigned a number
patients number is cross-referenced with patients name and filed alphabetically
used in large clinics, group practices, and hospitals |
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Term
| Consecutive Numeric System |
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Definition
simplest type of numerical filing system
patients are assigned consecutive numbers in the order of the date of their first visit to the facility |
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Term
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Definition
patients assigned consecutive numbers as they visit facility
digits in patients numbers are separated into groups of 2 or 3
read groups from right to left and filed backward in groups |
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Term
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Definition
patients social security number is patients filing number
not every patient has a social security number |
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Term
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Definition
generally not used for medical records
indexed by subject matter then filed alphabetically, numerically, or both |
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Term
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Definition
colored tabs used to reperesent patient information at a glance
used on letters of the patients surname
can help prevent misfiling
selection of colors and division of alphabet depends on the practice
file alphabetically or numerically |
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Term
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Definition
organizes information chronologically for follow up
can be notations on daily calender, or card file divided into months and days
must be checked daily |
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