Chapter 14: Medical Records Management; Key Terms – Flashcards
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Accession record
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Log book used to assign numbers to correspondence or patients
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Caption
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Method of designation used on file guides
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Cross-reference
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Note in file to direct reader to specific record that may be filed under more than one name/subject (Married, maiden, foreign names)
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Indexing
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Selecting name, subject, or number under which to file a record and determining the order in which the units should be considered
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Key unit
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First indexing unit of the filing segment
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Out guide or sheet
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Card, folder, or slip or paper inserted temporarily in files to replace a record that has been retrieved from the files.
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Problem-oriented medical record (POMR)
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Patient chart record keeping that uses a sheet at a prominent location in the chart to list vital id data. Problems are identified by number that corresponds to charting.
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Purging
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Method to maintain order in files by separating active from inactive and closed files
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SOAP/SOAPER
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Subjective impressions Objective clinical evidence Assessment or diagnosis Plans for further studies Education for patient Response of patient to education and care given
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Source-oriented medical record (SOMR)
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Patient chart record keeping that has separate sections for different sources of patient info. Such as lab reports, pathology reports, progress notes
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Tickler file
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System to remind of action to be taken on a certain date
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Unit
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Each part of a name, words, or numbers that will be indexed and coded for filing
