CHAPTER 10: MEDICAL RECORDS MANAGEMENT – Flashcards
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active patient files
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files for patients who have appointments or who have been in to see the physician recently
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advance directives
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documents that outline patients' wishes regarding health care should those patients be unable to speak for themselves
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Center for Medicare and Medicaid Services (CMS)
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agency that oversees Medicare and Medicaid services
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chief complaint
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main reason a patient seeks care
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closed patient files
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files for patients who will not be returning to the clinic
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cross-referencing
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method of tracking and finding patient files for patients with multiple last names
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electronic medical records
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medical records kept via computer; also called electronic health records
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electronic signature
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electronic version of a person's signature to be used in electronic medical records
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financial information
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data on payment record or ledger, health insurance identification numbers, and policy numbers
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flow charts
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graphs in patient medical records that track such things as weight gain or newborn growth
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inactive patient files
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files for patients who have not seen the physician for extended periods
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indecipherable
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unreadable
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medical information
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information on a patient's medical care and history
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medical record
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legal document consisting of medical information obtained from the patient via consultations, examinations, and tests
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medical research program
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research conducted to determine the effectiveness or harm of certain medications or medical treatments
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narrative
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type of medical charting in which the health care provider writes a narrative version of patient contact
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nontherapeutic research
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research programs that fail to benefit the study's patients
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obliterate
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to make unreadable or unrecognizable
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problem-oriented medical record (POMR) charting
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type of medical record charting that focuses on patients' health care problems and addresses those problems at each visit
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progress notes
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notes in patients' medical charts outlining those patients' progress or complaints
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purge
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to remove closed or inactive patient medical records from the medical office
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shingling
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process of attaching small pieces of paper to standard-size sheets of paper so the small items are easy to locate in patients' charts
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SOAP note charting
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type of charting that considers the patient's subjective and objective findings, the provider's assessment of the patient's condition, and the prescribed plan of action for treatment
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social information
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information about a patient's social habits, such as tobacco, drug, or alcohol use
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standard of care
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legal term that describes the type of care a reasonable health care provider is expected to provide under the same situation
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statute of limitations
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period within which a patient must file a lawsuit after an injury
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subpoena
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court order demanding that a party appearance in court or copies of the medical record be sent to a third party
