Chapter 14, medical records management

question

Accession record (numeric system)
answer

Log book used to assign numbers to correspondence or patients
question

Caption
answer

Method of designation used on file guides
question

Cross-reference
answer

Notation on a file to direct the reader to a specific record that may be filed under more than one name/subject (e.g. married name/maiden name or foreign names) where the surname is not easily recognizable.
question

Indexing
answer

Selecting the name, subject, or number under which to file a record and determining the order in which the units should be considered.
question

Key unit
answer

First indexing unit of the file segment
question

Out guide or sheet
answer

Card, folder, or slip of paper inserted temporarily in the files to replace a record that has been retrieved from the files
question

Problem-oriented medical record (POMR)
answer

The type of patient chart recordkeeping that uses a sheep at a prominent location in the chart to list vital identification data. Patient medical problems are identified by a number that corresponds to the charting; for example, bronchitis is #1, a broken wrist is #2, and so forth.
question

Purging
answer

Method of maintaining order in the files by separating active from inactive and closed file.
question

SOAP/SOAPER
answer

Acronym for patient progress notes based on subjective impressions (S), objective clinical evidence (O), assessment or diagnosis (A), plans for further studies (P), education for the pt. (E), and response of pt. to education and care given (R).
question

Source-oriented medical record (SOMR)
answer

A type of patient chart record keeping that includes separate sections for different sources of patient information, such as laboratory reports, pathology reports, and progress notes.
question

Tickler file
answer

System to remind of action to be taken on a certain date
question

Unit
answer

Each part of a name (business or person), words, or numbers that will be indexed and coded for filing.

Get instant access to
all materials

Become a Member