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26 Cards in this Set
- Front
- Back
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What do nonconsecutive filing systems groups of? |
Consist of numbers |
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Who oversees confidentiality of patient records? |
The provider |
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List three examples of when medical records can be released without patient consent. |
1. When records are under subpoena 2. |
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List how to correct medical records both electronically and manually. |
Manually: Draw single line using red pen through error, make correction, write 'corr.' or 'correction' above the area, indicate your initials and the current date. Electronically: Draw a line through the error using the 'tracking' device, make correction, write 'corr.' or 'correction' above the area, indicate your initials and the current date. |
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Who owns hardcopy of patient's records? |
The creator (doctor) |
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Who owns the information that the patient's records have? |
The patient |
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Define outguide |
Used to track charts when removed from filing storage. |
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When filing, if a person has a title, where is it indexed? |
Title is indicated last. |
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When filing, what is the rule to follow when you have a letter title (Jr.) and a number title (III)? |
Numbers |
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What is a tickler file? How do you file things in a tickler file? What are the 4 items that need to be listed on a tickler file? |
They are used to remind you to do something in the future. The tickler files are done manually or electronically. Patient's name, date, action required and additional information is listed. |
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When you file using strict chronological order, how are you filing? |
In order of time and the most recent is placed foremost (on top) |
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What type of charting records the patient's problems by number? |
Problem oriented medical record |
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What is the Golden Rule of Documentation? |
If it is not written, it never happened. |
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What is the purpose of cross referencing? |
To identify the location of a file. |
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What is the best filing system when you have a large number of patients? |
Numeric filing |
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What do the terms "retention and purging" mean? |
Record purging is process of sorting through records and removing those that are not active. |
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The purpose of Medical recording is... |
Provide a base for managing patient care, determine patterns, serve basis for legal infomation |
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What is subpoena? |
An order from the court to produce documents, records etc. to be used as evidence |
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Define closed, inactive and active files. |
Closed: files no longer needed Inactive: Kept for possible use Active: current files |
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Define what the acronym SOAP stands for and where the information each comes from. |
S- subjective impressions O- objective clinical evidence A- assessment or diagnosis P- plans for studies/ treatments |
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The addition of ER at the end of SOAP stands for what? |
E- education for the patient R- response of patient to education and care given |
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If the patient calls with an unsatisfactory progress report, what do you do with the call? |
Defuse the situation, remain calm, and in control. Let the patient talk; do not interrupt. |
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Is an appointment book considered a legal document? |
Yes |
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What does the ADA stand for? |
Americas with disabilities act |
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What is the purpose for ADA? |
Requires health care providers to provide effective communication alternatives to people who may be deaf or hearing impaired. |
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If you ate on the phone and another call comes in, how should you professionally handle the situation? |
Excuse |
