Terms
Includes the same type of patient information as a paper record, but the information is stored digitally on a computer.
Electronic Health Record (EHR)
The patient's account of his/her illness.
Chief Complaint
Combines letters and numbers to arrive at a unique identifier for each patient.
Alphanumeric
Involves assigning colors to represent letters and numbers to aid in record filing and retrieval.
Color coding
Entries about interactions with patients that are not office visits must be made in the record by the physician, nurse, assistant, or other medical office staff members.
Chart Notes
Records of patients who are currently undergoing or have recently undergone treatment.
Active records
Records of patients who have died, who have moved from the area, or who will likely not return for treatment in the future.
Closed records
Releasing medical information that should not be released.
Breach of confidentiality
Provides a synopsis of the patient's hospital treatment.
Discharge Summary
Records of patients who have not received treatment over a specified period of time.
Inactive files
Easiest of all the filing systems. Charts are filed in the order of lowest to highest number.
Consecutive Number Filing
When a patient is referred by a primary physician to a specialist, the encounter between the patient and the specialist is called what?
Consultation
Involves reversing the order of some of the digits.
Transposition
Plastic envelope with pockets; used to mark the place from which a medical record was removed.
Outguide
Includes questions about the patient's history of disease and injury, questions about the family medical history, and perhaps even a summary of current symptoms.
Medical History
Used to keep track of each number as it is assigned to a patient.
Accession ledger
Related information grouped together in a patient's medical record.
Source-oriented medical record (SOMR)
System that reminds an assistant to perform a certain activity at a certain time.
Tickler File
One of the most common methods of documenting patient visits in a chart note.
SOAP method
Filing method that allows a patient's medical record to be easily located in the case of a name change.
Cross-reference
Involves directing and organizing all activities related to keeping and caring for information concerning health care provided for patients.
Health Information Management
This form specifies in writing what medical information regarding the patient should be released.
Release of Information (ROI)
Contains the patient's insurance information and basic demographic data such as the patient's complete name, address, date of birth, telephone number, employer, and next of kin.
Summary Sheet
Contain descriptions of body tissue that has been sent to a medical lab for study.
Pathology Reports
Involves breaking the chart number into a series of groups and filing within each group.
Terminal Digit Filing