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43 Cards in this Set
- Front
- Back
- 3rd side (hint)
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Medical records and electronic medical records can be used to record |
Statistical information |
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Medical records document all aspects of |
Pt care |
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Medical records are |
Legal documents used by physician if there are questions about the care given |
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Physical record |
Belongs to medical office |
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Information inside |
Belongs to pt |
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Paper and electronic records |
Provide continuity of care Provides ongoing record of pts health Legal document Usually includes info from more than one source |
4 bullets |
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Storage |
Equipment for pt medical records |
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File folders |
Manila file folders with tabs are used to protect records |
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Recommended folders broke down in 2 sep folder once folder reaches |
3/4 inch |
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Allergies are usually in |
Red |
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Pressure sensitive self adhesive labels are usually |
Used |
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Color coded labels/ files reduces risk of |
Misfiling |
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Mounting sheets |
8 1/2 x 11” but also 9x12 Oldest to newest |
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“Outguides” (highlight) |
Makes it easier to find |
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New pt |
Format usually used is source oriented medical records doc filed in revere chron order |
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Purpose of filing system |
One individual record can be efficiently located |
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Alphabetic filing |
Each part of the name considered indexing unit |
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Indexing unit |
Piece of info used to identify the correct filing location |
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Rule 1: individual names |
Surname, given name middle name Name w/2 before name w/3 |
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If nickname used on record |
Index as if legal name |
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Numeric terms |
Indexes in numeric order before alphabetical terms |
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Hyphenation |
Indexed as one unit |
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Numeric filing |
Indirect method of fling number must be identified Easier w/large pract and with pt with the same surname |
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Terminal Digital Filing System |
Used in large med office & hospital 6 digit number w/hyphens b/w each group |
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Terminal digit filing system |
Go from front to back Each group of two digits is a filing unit |
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Nonconsecutive filing |
May also consist of assigning each pt a combo of both letters & numbers |
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Consecutive filing |
Numbers are arranged and filed from lowest to highest Zeros first unit so each number has the same number of digits |
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Subject filing |
Documents may be arranged according to subjects Alphabet or chronological Used for items necessary to manage MO |
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Chronological filing |
Should be located where MA sits Number or dates |
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Tickler file |
A reminder System Can b set up on comp, cal, index cards or in file folder Date of action type action nec info |
Under chronological filing |
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Retrieving pt record |
Each time a record is taken from storage an out guide is placed exactly where the record was removed Card / guide saying who has record |
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Filing reports & correspondence |
All reports letters and materials that come to the office should be reviewed and initial by dr bfore filing |
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Dictated progress notes must also be review and initial by dr & |
F/u should be completed before filing |
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Electronic med record |
Kept available for 2-3 years |
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Storing med record |
Stored in well lighted area & climate controlled Humidity b/w 48%-52% Protected from dust insects rodents fires floods |
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Storing according to OSHA |
Main aisle or entrance to rooms much be 5ft wide and secondary aisles at least 3ft wide Records should be secure when office is closed |
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Inactive records |
Pts who have not been seen w/in the time period specified by practice Move from active file to create more space for new records |
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Retention of records |
Length of time a medical record must b retained is difficult to determine |
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Retention each state has a law limiting |
The time period for beginning a lawsuit for malpractice |
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Statute of limitations for medical malpractice |
Time period for beginning a lawsuit for malpractice |
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For minors |
Statute of limitations should be considered to begin at the age of majority |
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Retention continue |
Back (Definition) |
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Storing computerized records |
Back (Definition) |
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