MOD A UNIT 3 VOCAB

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Author:
jmejamison
ID:
68993
Filename:
MOD A UNIT 3 VOCAB
Updated:
2011-03-04 13:51:36
Tags:
MEDICAL RECORDS CHART DOCUMENTATION
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Description:
MEDICAL RECORDS & CHART DOCUMENTATION
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  1. What replaces a file folder when it is removed from the file cabinet?
    Out guides
  2. What is a chart format that is arranged according to a pt's health complaint?
    Problem-oriented medical record (POMR)
  3. What is a type of chart format that divides each patient problem into subjective data, objective data, assessment, and plan for treatment?
    SOAP
  4. What is the method of filing that organizes recoreds by their final digits?
    Terminal-digit filing
  5. What is a reminder aid that organizes events by date and should be checked frequently and organized for use?
    Tickler file
  6. Who owns the information in a medical chart?
    The patient
  7. What provides evidence of patient assessments, interventions, and communications?
    Medical records
  8. Continuity of care, filing insurance claims, and resolving legal matters are examples of using what kind of record?
    Patient record
  9. Planning & Care: This is a legal form that protects all health care personnel when caring for the patient by signifying that the pt has been informed of treatment risks and alternatives
    Consent to treat form
  10. Who owns the pts medical records
    The physician
  11. An organized medical record that has dividers to separate the medical information and is grouped by the type of service provided is in what format?
    Source-oriented record format
  12. Information provided by the pt as a CC is what type of data? (feels like nails into my head)
    Subjective
  13. Information obtained through the physical examination; observed or seen is what kind of data?
    Objective
  14. The impression the Dr. has about a pts symptoms: aka a preliminary diagnosis is a what?
    Assessment
  15. The plan of action or treatment including diagnostic testing and medications?
    Plan
  16. National mandate states never to use what while correcting in a pts chart, and what do they advise?
    Never use white out, instead draw a line through the error and write correction and initial.
  17. What is the most common method of filing and is broken into units?
    Alphabetical
  18. When alphabetizing the last name is the what (first unit)?
    Key unit
  19. What is the 2nd unit when filing alphabetically?
    First name or initial
  20. How would "St." be indexed when filing alphabetically?
    As if it were spelled out "Saint"
  21. What type of system can be used with alphabetical or numerical filing and should be known by everyone in the office?
    Color coding

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