Ch.14 The Paper Medical Record
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Alphabetic Filing
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Any system that arranges names or topics according to the sequence of the letter in the alphabet
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Alphanumeric
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Of or relating to system made up of combinations of letters and numbers
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Audit
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A formal examination of an organization's or individual's account or financial situation; a methodic examination and review
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Augment
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To make greater, more numerous, larger, or more intense
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Caption
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A heading, tittle, or subtitle under which records are filed
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Chronological Order
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Of, relating to, or arranged in or according to the order of time
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Continuity of Care
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Continuation of care smoothly from one provider to another, so that the patient receives the most benifit and no interruption in care
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Dictation
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The act or manner of uttering words to be transcribed
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Direct Filing System
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A filing system in which materials can be located without consulting an intermediary source of reference
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Gleaned
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Gathered bit by bit; picked over in search of relevant material
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Indirect Filing System
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A filing system in which an intermediary source of reference must be consulted to locate specific files
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Microfilm
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A film with a photographic record of printed or other graphic matter on a reduced scale
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Numeric Filing
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The filing of records, correspondence, or cards by number
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Objective Information
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Information of records, correspondence, or observing a patient
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Obliteration
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The act of making undecipherable or imperceptible by obscuring or wearing away
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OUTfolder
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A folder used to provide space for the temporary filling of materials
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OUTguide
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A heavy guide to replace a folder temporarily removing the filling space
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Power of Attorney
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A legal instrument authorizing a person to act as the attorney agent of grantor
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Pressboard
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A strong, highly glazed composition board resembling vulcanized fiber; heavy card stock
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Procrastination
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Intentional postponement of doing something that should be done
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Provisional Diagnosis
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A temporary diagnosis make before all test results have been received
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Purging
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The process of many active files to in active status
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Quality Control
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An aggregate of activities designed to ensure adequate quality, especially in manufactured products or in the service industries
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Requisites
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Entities considered essential or necessary
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Retention Schedule
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A method or plan for retaining or keeping medical records and for their movement from active, to in active, to closes filing
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Reverse Chronologic Order
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Arranged in order so that the most recent item is on top and older items are filed further back
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Shingling
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A method of filing in which a report is laid on top of the older report,resembling the shingles of form
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Subjective Information
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Information gained by questioning the patient or taking information a form
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Transcription
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A written copy of something made either in long hand or by machine
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Vested
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Granted or endowed with a particular authority, right, or property; to have a special interest in
