Chapter 41MAA Medical Record Management – Flashcards
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Acronym
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A word formed from the first letters in a name
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Active record
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The medical record of a patient who has been seen within a time frame specified by the office (usually 2-3 years)
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Cross-index
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To file under one unit and use a guide or card filed under another unit that refers to the primary filing location
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Electronic health record (EMR)
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An individual patients health record in digital format. Also called an Electronic medical record
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Filing system
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The way in which records are arranged. Common filing systems in the medical office include: alpahbetic, numeric, by subject, or chronologic
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Health information exchange (HIE)
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The electronic exchange of health care-related data among different institutions
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Inactive record
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The medical record of a patient who has not been seen within the last 2-3 years, or some other time frame specified by a given medical office
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Medical record management
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Activities related to the creation, management, use, and disposition of patient medical records
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Nationwide Health Information Network (NHIN)
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A set of standards, services, and policies to facilitate national HIE (health information exchange)
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Outguide
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A cardboard or plastic card to insert in a file when a medical record is removed
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Sorter
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A device that facilitates putting papers or records in alphabetic or numeric order
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Surname
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Last name or family name of an individual; used as the first indexing unit in alphabetic filing
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Tab
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A projection of a folder that extends beyond the top or side of the folder
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Terminal digit filing
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A chronologic filing system that uses the last number or number group as the first indexing unit
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Indexing units
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Pieces of information used to identify a correct filing location
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Paper-based medical records
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Many medical records still rely on this to document care
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What are 2 things EMR's offer as an advantage
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Medical information is always legible and Information is easy to retrieve
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Name 2 types of storage equipment
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File cabinets and shelf filing units
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Name 3 things you need for filing supplies
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File folders, folder labels, and chart dividers
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What are the 2 types of filing systems
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Alpahbetic and numeric
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Name the 8 rules for Alphabetic filing
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Individual names, Prefixes, Abbreviations and nicknames, Hyphenation, Titles and Seniority terms, Names of Married women, Companies and Businesses, and Identical names
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Name the 2 types of Numeric filing
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Terminal digit filing and Consecutive filing
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Consecutive Filing Systems
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numbers are arranged and filed from the lowest to the highest.
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Tickler file
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used to 'tickle' the memory by serving as a reminder that a specific action must be taken on a specific date, is a type of chronologic system
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Statute of limitations
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Each state has a law limiting the time period for beginning a lawsuit for malpractice
