Paper Medical Records

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Established patient
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patient previously seen in the office
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intermittent
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Coming and going at different times
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Matrix
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A base on which to build
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Alphabetical Filing
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System that arranged names or topics according to letters in the alphabet
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Audit
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A formal examination of accounts, fiances, or systems
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Chronological Order
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arranged according to time
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Continuity of Care
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care that continues from one MD to another without a break
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Direct filing system
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A filling system where files can be found without looking in a intermediary source of reference
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Numeric Filing
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Filing by numbers
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Objective Information
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Information that is gathered by watching/observing a patient
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OUT guide
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a heavy guide used to replace a folder that was removed
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Power of Attorney
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Legal paper allowing one to act as the attorney or agent for someone else
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Provisional Diagnosis
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A temporary diagnosis made before all test results are in
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Quality Control
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Activities to make sure adequate qualities in products or procedures
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Retention Schedule
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Plan for keeping medical records and their being moved from active to inactive
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Shingling
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Method of filing wherein reports is laid on top of the older report resembling the shingles of the roof
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Inpatient
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A patient that will be admitted to the hospital
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Outpatient
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A patient that will be seen at the hospital but not admitted
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Demographic
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Statistical information of human population use to identify different markets
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Mnemonic
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A device such as sentence or rhyme used as a memory aid
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Purging
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process of moving a file from active to inactive status
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EHR
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Electronic health record
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EMR
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Electronic medical record
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Progress notes
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Patients Medical History
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Darvocet N-100
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Used for relief of mild to moderate pain
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Calan SR
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Use to treat hypertension
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Wellburtin SR
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Use to treat major depression
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Klonopin
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Use to treat seizure disorder and panic disorder
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Singulair
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To treat asthma
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Missed appointments
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must be noted in the medical record
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Open office hours are also called
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tidal wave scheduling
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Wave scheduling
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allows flexibility to accommodate the unpredictable
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Patients should wait no longer than
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15 minutes
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Schedule late patients for
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Last of the day
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Canceled appointment
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remove first appointment day and time from schedule before making a new one
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SOAP
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subjective , objective , assessment , plans
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Subjective information
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from what the patient tells you
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Objective information
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what you observe from the patient
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Indexing rules
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last name 1 , first name 2 , middle name or initial 3
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Releasing record
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placing a mark that indicates it is ready for filing
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Flagged
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A reminder that specific actions need to be taken
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