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21 Cards in this Set

  • Front
  • Back
Who is the owner of your medical records?
Physician is the legal owner of the information in the medical records
How do you get your medical records transferred?
Only be released with a written release from the patient
SOR
Source Oriented medical Records
POR
Problem Oriented medical Records

** Most used by specialists
SOAP
Subjective
Objective
Assessment
Plans
Chief Complaint
Patients complaints or symptoms in their own words
Obliteration
of an entry in a medical record is never acceptable
Closed files
Patients who have died, moved away, or otherwise discontinued treatment
How long should files be kept on a minor from the time they reach legal age?
at least 3 years
Continuity of Care
Care continues smoothly from one provider to another, and the patient receives the best benefit
POA
*Power Of Attorney
**allowing one to act as the agent of the grantor
How long should you keep records on a deceased patient?
at least 2 years
Tickler file
Follow up system used to help remember when a certain task needs to be done
Indirect file system
a system in which an intermediary source of reference, such as a file card, must be consulted to locate specific files
Shingling
method of filing where one report is laid on top of the older report, resembling a roof
Indexing rules
Last name, first name middle name or initial

**ex. Adams, John Mr.
Quality assurance
Activities designed to increase the quality of a product through system changes
Augment
To make greater, more numerous or more intense
Vested
Granted or endowed with a particular authority
Sentinel event
a total power failure in a hospital
nosocomial infection
usually acquired in a hospital