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39 Cards in this Set

  • Front
  • Back

The way patient's records are created filed and maintain

Records management system

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

Records are stored in a circular fashion similar to a revolving door and our excess by rotating file of

Rotary circular file

Is the most basic filing supply in the medical office

File folder

when returning patient documents to their medical record or returning record themselves to their properly filed location

The coding step

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

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

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

Such as Dr. or major should be treated as the last filing unit

A patient's title

Is used when there is a need to distinguish files within a filing system

Color coding

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

External factors that can be seen or felt by the physician or measured by an instrument

Signs are objective

Internal conditions that are felt by the patient but I'm not necessarily a parent and a physical examination

Symptoms are subjective

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

Section of soap documentations contains data from the physicians examination and test results

O or objective

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

You must obtain the before releasing the patient's record

Patient signature or written release statement

When you release medical information to confirm that all materials were received

Call the recipient

Are done by the medical staff on randomly chosen records

Internal audit

Are used to send documents or material such as slides that maybe damage in the normal course of mail handling

Padded envelopes

Involves check and a document for factual accuracy logical flow consciousness clarity and tone

Editing

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

Tells you how to spell divide and pronounce a word and what part of speech is

Dictionary

A dictionary of medications that is published yearly

PDR OR physicians desk reference

Was formally known as fourth class mail

Parcel post

Can be used for first class items that way between 11 ounces and 70 pound

Priority mail

Is aligned with a complementary closing and place 3 to 4 lines below to allow space for the signature

Signature block

Two styles of punctuation using correspondence are

Open punctuation and close punctuation

Business letter should be in the

Active voice unless you are conveying negative news

Can't be cotton fiber bond or sulfite bond

Letterhead paper

The items in a list but leave an extra line between items

Single space

Is aligned with a complementary closing

Signature block

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

Is one of the most commonly used for Matt and medical offices because it is quick and easy to write

Full block style

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

Three types of errors that can occur when you are preparing a document

Formatting data and mechanical errors

Is the quickest USPS service providing next day and second day delivery 365 days a year

Express mail

Deliver packages and provide overnight letter in express services

UPS FedEx and DHL

Sent by medical office should sound professional because it represents your medical office to the recipient

All electronic mail