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39 Cards in this Set
- Front
- Back
The way patient's records are created filed and maintain |
Records management system |
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Are kept on rolling shelves that slide along permanent tracks in the floor so that they can be stored close together when not in use to converse space |
Compactible files |
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Records are stored in a circular fashion similar to a revolving door and our excess by rotating file of |
Rotary circular file |
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Is the most basic filing supply in the medical office |
File folder |
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when returning patient documents to their medical record or returning record themselves to their properly filed location |
The coding step |
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To keep the document from being lost in the file or falling out you can use blank allow smaller documents to be attached to a standard size sheet or if it has writing on both sides place it in a standard size plastic sheet protector |
Special paper containing self-adhesive areas |
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You may not be able to duplicate the information within the file but you can try to buy contacting insurance companies laboratories and other providers for copies of the original documents |
Reconstruct it |
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Typically makes the decision of how long to keep an active or close files in the office before sending them to the storage |
The physician |
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Such as Dr. or major should be treated as the last filing unit |
A patient's title |
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Is used when there is a need to distinguish files within a filing system |
Color coding |
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Summary generally includes information that summarizes the reason the patient entered the hospital test procedures and operations performed medications administered in the disposition or outcome of the case |
Hospital discharge summary |
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External factors that can be seen or felt by the physician or measured by an instrument |
Signs are objective |
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Internal conditions that are felt by the patient but I'm not necessarily a parent and a physical examination |
Symptoms are subjective |
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Documentation contains subjective data from the patient and includes the patient's description of his or her signs and symptoms opinions and comments |
S section of soap |
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Section of soap documentations contains data from the physicians examination and test results |
O or objective |
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Information corrected or added sometime after a patient visit can be regarded as blank and many damage the position to position in a lawsuit |
Convenient |
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You must obtain the before releasing the patient's record |
Patient signature or written release statement |
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When you release medical information to confirm that all materials were received |
Call the recipient |
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Are done by the medical staff on randomly chosen records |
Internal audit |
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Are used to send documents or material such as slides that maybe damage in the normal course of mail handling |
Padded envelopes |
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Involves check and a document for factual accuracy logical flow consciousness clarity and tone |
Editing |
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To create effective professional correspondence that reflects well on the practice be sure that you use |
Clear and concise language the active voice and appropriate style |
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Tells you how to spell divide and pronounce a word and what part of speech is |
Dictionary |
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A dictionary of medications that is published yearly |
PDR OR physicians desk reference |
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Was formally known as fourth class mail |
Parcel post |
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Can be used for first class items that way between 11 ounces and 70 pound |
Priority mail |
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Is aligned with a complementary closing and place 3 to 4 lines below to allow space for the signature |
Signature block |
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Two styles of punctuation using correspondence are |
Open punctuation and close punctuation |
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Business letter should be in the |
Active voice unless you are conveying negative news |
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Can't be cotton fiber bond or sulfite bond |
Letterhead paper |
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The items in a list but leave an extra line between items |
Single space |
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Is aligned with a complementary closing |
Signature block |
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Includes information such as the number of enclosures included with the weather and the names of other people who were receiving copies of the letter |
Notation |
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Is one of the most commonly used for Matt and medical offices because it is quick and easy to write |
Full block style |
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No the type of person to whom you're writing and decide at the time should be formal or more relaxed |
Before you write a letter |
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Three types of errors that can occur when you are preparing a document |
Formatting data and mechanical errors |
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Is the quickest USPS service providing next day and second day delivery 365 days a year |
Express mail |
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Deliver packages and provide overnight letter in express services |
UPS FedEx and DHL |
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Sent by medical office should sound professional because it represents your medical office to the recipient |
All electronic mail |