MDA 1051 – Chapter 41 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 to 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 (EHR)
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An individual patient's health record in digital format. Also called an electronic medical record.
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Electronic medical record (EMR)
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An individual's medical record in digital format. Also called an electronic health 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 alphabetic, 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 past 2 to 3 years, or some other time frame specified by a given medical office.
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indexing units
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Pieces of information used to identify a correct filing location.
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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 of 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 that last number of number group as the first indexing unit.
