Unit 3 Spelling

Front 1

Accession record

Back 1

Log book used to assign numbers to correspondence or patients

Front 2

Caption

Back 2

Method of designation used on file guides

Front 3

Cross-reference

Back 3

Notation in a file to direct the reader to a specific record that may be filed under more than one name/subject where the surname is not easily recognized

Front 4

Indexing

Back 4

Selecting the name, subject, or number under which to file a record and determining the order in which units should be considered

Front 5

Key unit

Back 5

First indexing unit of the filing segment

Front 6

Out guide

Back 6

Card, folder or slip of paper that temporally is used in files to replace a record that has been removed

Front 7

Problem oriented medical record

Back 7

A type of patient chart record keeping that uses a sheet at a prominent location in the chart to list vital identification data

Front 8

Purging

Back 8

Method of maintaining order in the files by separating active from inactive files

Front 9

SOAP

Back 9

Acronym for patient progress notes based on the subjective impressions. S subjective O objective A assessment P plan

Front 10

Source oriented medical record

Back 10

A type of patient chart record keeping that includes separate sections for different sources of patient information

Front 11

Tickler file

Back 11

System to remind of actions to be taken on a certain date

Front 12

Association for health care documentation integrity

Back 12

Professional organization that in the field of medical transcription editing

Front 13

Auditor

Back 13

A person responsible for determining the final content of a document and the documents correctness

Front 14

Autopsy report

Back 14

A medical examiners report to determine the cause of death or to a certain and confirm disease presence

Front 15

Certified medical transcriptionist

Back 15

Completion of a two part certification examination administered by the association for health care documenting integrity

Front 16

Chart notes

Back 16

Also called progress notes, providers formal or informal notes presenting problems, physical findings and plans for treatment for a patient

Front 17

Chief complaint

Back 17

Specific symptoms or problems for which a patient is being seen for

Front 18

Confidentiality

Back 18

Ethical and legal rules in regard to patient privacy

Front 19

Confidentiality agreement

Back 19

When signed, the agreement signifies that the medical transcriptionist is committed to keep all patient information confidential

Front 20

Consultation report

Back 20

Document that reports the findings and advice of another provider requested to see a patient by the attending provider

Front 21

Current reports

Back 21

Reports such as history and physical examination that should be complete within 24 hours

Front 22

Discharge summary

Back 22

Medical reports that document the hospitalization history of a patient

Front 23

Editor

Back 23

Corrector

Front 24

Electronic medical record

Back 24

A patients electronic medical records

Front 25

Flag

Back 25

Method of.identofying a blank space or question

Front 26

Gross examination

Back 26

Viewing specimen with the naked eye

Front 27

Health insurance probability and accountability act

Back 27

Government rules regulations and procedures resulting from legislation designed to protect the confidentiality of a patient information

Front 28

History and physical examination

Back 28

Reports of patient history and physical examination to document reason for visit

Front 29

History of the present illness

Back 29

The chronological description of the development of patient illness

Front 30

Microscopic examination

Back 30

Viewing a specimen with the aid of a microscope

Front 31

Old report or aged

Back 31

Reports such as a discharge report summary

Front 32

Operative report

Back 32

Medical report that chronicles the details.of surgical procedure

Front 33

Pathology report

Back 33

Medical record that generated to describe the gross and microscopic examination performed during a surgical procedure

Front 34

Present problem

Back 34

Problem the patient is being seen for

Front 35

Privileged

Back 35

Confidential information that may be communicated with the patients permission or by court order

Front 36

Progress noted

Back 36

Also called.chart notes providers formal or.informal notes about presenting problems

Front 37

Quality assurance

Back 37

Process to provide accurate, complete, consistent health care documentation in a timely.manner while making every reasonable effort.to resolve inconsistencies

Front 38

Radiology report

Back 38

Medical reports that describe the findings and interpretation of the radiologist

Front 39

Review of systems

Back 39

Inquires about the system directly related to the problems identified in the history of the present illness

Front 40

Voice recognition system

Back 40

Software that translates voice commands and is used in place of a mouse pad or keyboard

Front 41

Biometric

Back 41

Technologies that measure and analyze human body characteristics such as DNA

Front 42

Malpractice

Back 42

Professional negligence