Medical Office Chapter 5

Front 1

accession book

Back 1

A book containing a list of consecutive numbers used to assign each patient a number in practices where a numeric filing system is used. See also numeric filing.

Front 2

active files

Back 2

Those records belonging to patients currently seeing the physician.

Front 3

AHIMA

Back 3

American Health Information Management Association. A national organization that serves health information management professionals, keeps professionals current with legislation, and provides consumers of health services with topics of interest to them.

Front 4

alphabetic filing

Back 4

A system of filing whereby documents are kept according to names, titles, or classifications in alphabetical order.

Front 5

application software

Back 5

Computer programs that apply the computer's capabilities to specific uses, such as word processing, graphics, database management, and spreadsheets.

Front 6

ARMA

Back 6

Association of Records Managers and Administrators. An international association that includes among its members information managers, archivists, librarians, and educators; sets standards for filing, record retention, and other aspects of records management.

Front 7

assessment

Back 7

The physician's interpretation of subjective and objective findings as contained in the SOAP record; also called "diagnosis" or "impression."

Front 8

CHEDDAR

Back 8

A system of documenting medical data in a patient's chart using sequential categories: chief complaint, history, exam, details of problem/complaint, drug data, assessment, and return visit or referral.

Front 9

closed files

Back 9

The records of those patients who have moved away from the area, died, or terminated their relationship with the physician.

Front 10

coding

Back 10

1. The placing of a number, letter, color, or underscore beneath a word to indicate where a document should be filed.

2. The process of assigning codes to diagnoses and treatments based on standard code sets.

Front 11

color-coding

Back 11

The organization of files according to a system of colored file folders.

Front 12

cross-reference sheet

Back 12

The indication, made on a sheet of paper or card, of other files where a copy of a particular document may be found.

Front 13

database

Back 13

The complete history of a patient as contained in a problem oriented medical record (POMR); Includes the problem, medical, social, and family histories, a review of systems, and the physician's conclusions; also ay collection of related data, sets, or subsets of information.

Front 14

dead storage

Back 14

An area reserved for records that have been closed or that must be stored permanently; usually physically separate from where active files are kept.

Front 15

diagnosis (Dx)

Back 15

A term used interchangeably with “assessment”

or “impression”; gives a name to the condition from which the patient is suffering.

Front 16

electronic health records (EHRs)

Back 16

Healthcare databases compiled over the course of different patient encounters.

Front 17

family history (FH)

Back 17

Facts about the health of the patient’s parents, siblings, and other blood relatives that might be significant to the patient’s condition.

Front 18

file server

Back 18

A central computer within a computer network, used to store the computer programs and data that must be shared by all the computers in the network; also called, simply, a “server.”

Front 19

folders

Back 19

Containers used to hold those items that are to be filed;

frequently made of a sturdy material to wit h stand handling.

Front 20

graphics application

Back 20

A software program that allows the user to manipulate images and to create original images electronically.

Front 21

guide

Back 21

A rigid divider placed at the end of a section of files to

indicate where a new section or category of files begins.

Front 22

history of present illness (HPI)

Back 22

Information taken from the patient about symptoms: when they began, what factors affect them, what the patient thinks is the cause, remedies tried, and any past treatment for the symptoms.

Front 23

impression

Back 23

A term used interchangeably with “assessment”

or “diagnosis”; gives a name to the condition from which the patient is suffering.

Front 24

inactive files

Back 24

The records of those patients who have not seen

the doctor for six months or longer.

Front 25

indexing

Back 25

The process of selecting the name, title, or classification

under which a document or an item will be filed.

Front 26

inspecting documents

Back 26

The act of checking each item received for filing to be sure that the information is complete and that the item is in good physical condition.

Front 27

Internet

Back 27

A vast, worldwide computer network that links millions of computers; enables almost instantaneous sharing of information in various digital forms—text, graphics, sound, video, and so on.

Front 28

label

Back 28

An oblong piece of paper, frequently adhesive, used to

identify a file by title or subject.

Front 29

laptop

Back 29

A portable computer, designed to fit into a briefcase;

able to run on either plug-in current or batteries.

Front 30

lateral files

Back 30

Drawers or shelves that open horizontally where files are arranged sideways from left to right instead of from front to back.

Front 31

mainframe

Back 31

A computer designed to store massive databases

that many users may all access at the same time.

Front 32

meaningful use

Back 32

Set of standards defined by CMS that specify how EHRs are to be used and allow eligible providers to earn

financial incentives for the use of certified EHRs by meeting stated objectives.

Front 33

medicolegal

Back 33

A type of document that provides evidence of patient care and is considered a legal document in a court of law.

Front 34

micrographics

Back 34

The process of storing records in miniaturized images, usually in a microfiche sheet or ultrafiche format, viewed on readers that enlarge the images.

Front 35

minicomputer

Back 35

A computer having less power than a mainframe;

may operate for a single user or along with many

terminals.

Front 36

mobile-aisle files

Back 36

Open-shelf files that are moved manually or

by motor.

Front 37

networking

Back 37

A means of communicating, exchanging information,

and pooling resources among a group of electronically

linked computers.

Front 38

numeric filing

Back 38

A system of document storage in which each

patient is assigned a number; see also accession book.

Front 39

objective

Back 39

The physician’s examination of the patient contained

in the SOAP record; results of the examination may be shown under the heading “Physical Examination (PE).”

Front 40

online

Back 40

Connected to a computer network for purposes of

communicating, gathering, or exchanging information.

Front 41

open-shelf files

Back 41

Shelves that hold files, may be adjustable or fixed, and may extend from floor to ceiling; shelves accept files

placed sideways with identifying tabs protruding.

Front 42

operating system

Back 42

The internal programming that tells the computer how to use its own components by controlling the basic functions of the computer and directing the computer to interact with the user and with i n put and output devices.

Front 43

out guide

Back 43

A card placed as a substitute for a file folder;

indicates that a file has been removed.

Front 44

output device

Back 44

A device used to display electronic data.

Front 45

password

Back 45

A code assigned to a computer user as a security

measure; limits access to computer files and safeguards

information.

Front 46

past medical history (PMH)

Back 46

A listing of any illnesses the patient has had in the past; includes treatments and procedures performed.

Front 47

personal computer

Back 47

A computer designed for one user; may reside on a desktop or may be portable, as laptop and notebook

computers are; referred to as “PCs” or, less frequently, as “microcomputers.”

Front 48

physical exam (PE)

Back 48

A complete examination of the patient in which findings for each of the major areas of the body are stated or an examination that covers only the body systems pertinent to that particular visit.

Front 49

plan

Back 49

The treatment, as stated in the SOAP record, listing

prescribed medication, instructions given to the patient, and recommendation for surgery or hospitalization.

Front 50

problem-oriented medical record (POMR)

Back 50

A patient record organized around a list of the patient’s complaints or problems; contains a database of the patient’s history, initial plan, and problem list.

Front 51

records management

Back 51

The systematic control of the steps in the life of a record, from its creation through its maintenance to its disposition.

Front 52

releasing

Back 52

The indication, by initial or by some other agreed upon

mark, that a document has been inspected and acted

upon and is ready for filing.

Front 53

retention

Back 53

The length of time that records are kept; regulated in

many cases by state law; also regulated by Medicare.

Front 54

review of systems (ROS)

Back 54

The physician’s specific questions to the patient about each of the body’s systems.

Front 55

rule out (R/O)

Back 55

A possible diagnosis that must be proved or “ruled out” by further tests. In the outpatient setting, a rule out diagnosis cannot be submitted to an insurance carrier—only confirmed signs and symptoms can be submitted.

Front 56

SOAP

Back 56

An acronym used to refer to the most common system

for outlining and structuring notes on a patient’s chart; the acronym stands for the headings used: Subjective, Objective, Assessment, and Plan.

Front 57

social history (SH)

Back 57

Information that may be pertinent to treatment regarding the patient’s marital history; occupation; interests; and eating, drinking, and smoking habits.

Front 58

sorting

Back 58

The arrangement of documents in the order in which

they will be filed.

Front 59

spreadsheet programs

Back 59

Software used for financial planning and budgeting.

Front 60

storing

Back 60

The placement of an item in its correct place in a file;

also called “filing.”

Front 61

subject filing

Back 61

A system of document storing whereby the placement

of related material is alphabetic by subject categories.

Front 62

subjective

Back 62

The patient’s description of the problem or complaint,

including symptoms, when symptoms began, associated

factors, remedies tried, and past medical history.

Front 63

supercomputer

Back 63

The most powerful computers available.

Front 64

tab cuts

Back 64

Position of tab on file folder.

Front 65

tabs

Back 65

A projection that extends beyond the rest of the file folder so that the folder may be labeled and easily viewed.

Front 66

template

Back 66

A standard electronic version of a frequently used document; may be altered slightly from one use to the next; saves user time in keying and formatting commonly used documents and forms.

Front 67

transcription

Back 67

A method of recording data whereby the medical provider dictates data into a recording device and an individual trained in medical keyboarding skills keys the information into documentation format.

Front 68

vertical files

Back 68

Drawer files, contained in cabinets of various sizes; files are arranged from front to back.

Front 69

virus

Back 69

A malicious computer program written with the intent of harming other data, software, and/or computers.

Front 70

voice-recognition technology

Back 70

A program used along with a word processing application to transcribe spoken words into text without the use of a keyboard.

Front 71

wireless communication

Back 71

The use of radio waves rather than wires or cables to transmit data through a computer network.

Front 72

word processing program

Back 72

Software used to enter, edit, format, and print documents.