kinns ch14 the paper medical record
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alpabetic filing
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Any system that arranges names or topics according to the sequence of the letters in the alphabet
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alpha numeric
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Consisting of or using both letters and numbers
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audit
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an inspection of the accounting procedures and records by a trained accountant or CPA
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augment
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enlarge or increase
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caption
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a heading, title, or subtitle under which records are filed.
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chronologic 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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continuing of patient care from one physician to another
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dictation
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the act of saying words for someone else to write down
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direct filing system
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a filing system without source of reference
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gleaned
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Gathered bit by bit (e.g. information or material); 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, such as a file card, must be considered to locate specific files is called a:
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microfilm
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film on which materials are photographed at greatly reduced size
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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 that is gathered by watching or observation of a patient.
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obliteration
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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 filing of materials
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OUTguide
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A heavy guide that is used to replace a folder that has been temporarily moved from the filing space.
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power of attorney
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a legal instrument authorizing someone to act as the grantor's agent
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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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Intentionally putting off doing something that should be done
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provisional diagnosis
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A temporary diagnosis made before all test results have been received.
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purging
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The process of moving active files to inactive status.
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quality control
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the processes an organization uses to maintain its established quality standards
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requisits
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required or nessisary for a particular purpose
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retension schedule
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A method or plan for retaining or keeping medical records.
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shelf filing
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A system that uses open shelves rather than cabinets for storing records
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shingling
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filing in which a report is laid on top of the older report, resembling the shingles of a roof.
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subjective information
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Information that is gained by questioning the patient or taken from a form.
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tickler file
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A chronologic file used as a reminder that something must be taken care of on a certain date.
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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
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source-oriented records
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organized according to the source of documented information
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problem-oriented records
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are organized around the patient's problems
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SOAP
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subjective, objective, assessment, plan, Often used in the POMR plan
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CHEDDAR
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Chief complaint, History of present illness Examination, details, Drugs and Dosages, Assessment, Aeturn visit Information or Referral
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personal demographics
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identifying factors-correct full name, name of parents if pnt is a child, age, gender, date of birth, marital status, income, name of spouse if married, no. of children, home add, phone no, e-mail add, occupation, empl info for spouse, health ins info, ssn
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laboratory reports
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Instances of infection or disease in individuals confirmed by laboratory tests.
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radiology reports
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description of the findings and interpretations of the radiologist who studies the X-ray images taken of a patient
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addendum
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when a correction is made at a later date for hand written documents
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perpetual transfer method
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a method of transferring records continuously from active to inactive storage areas
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machine transcription
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dictating into a dictation unit/--istening to what was dictated--keying the dictated text to a printed document using correct format and punctuation
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indexing and coding
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deciding where to file the letter or paper and placing some indication of the decision on the paper
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indexing rules
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last name first, then first name, then middle name or initial, terms of seniority are used only to distinguish from another identical name
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subject filing
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arranging files according to their title, grouping similar subjects together.
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differential diagnosis
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attempt to determine which one of several diseases may be producing symptoms
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final diagnosis
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Conclusion a physician reaches after evaluating all findings, including lab and other test results
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active files
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patients currently receiving treatment
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inactive files
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Patients who have not been seen for about 6 months to a year
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closed files
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patients who have died, moved away, or otherwise discontinued treatment
