MOD A UNIT 3 VOCAB
Card Set Information
MOD A UNIT 3 VOCAB
MEDICAL RECORDS CHART DOCUMENTATION
MEDICAL RECORDS & CHART DOCUMENTATION
What replaces a file folder when it is removed from the file cabinet?
What is a chart format that is arranged according to a pt's health complaint?
Problem-oriented medical record (POMR)
What is a type of chart format that divides each patient problem into subjective data, objective data, assessment, and plan for treatment?
What is the method of filing that organizes recoreds by their final digits?
What is a reminder aid that organizes events by date and should be checked frequently and organized for use?
Who owns the information in a medical chart?
What provides evidence of patient assessments, interventions, and communications?
Continuity of care, filing insurance claims, and resolving legal matters are examples of using what kind of record?
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
Who owns the pts medical records
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
Information provided by the pt as a CC is what type of data? (feels like nails into my head)
Information obtained through the physical examination; observed or seen is what kind of data?
The impression the Dr. has about a pts symptoms: aka a preliminary diagnosis is a what?
The plan of action or treatment including diagnostic testing and medications?
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.
What is the most common method of filing and is broken into units?
When alphabetizing the last name is the what (first unit)?
What is the 2nd unit when filing alphabetically?
First name or initial
How would "St." be indexed when filing alphabetically?
As if it were spelled out "Saint"
What type of system can be used with alphabetical or numerical filing and should be known by everyone in the office?