The Keys
"cc"
chief complaint
A patient's medical record constitutes the _____ record of the medical practice.
legal
links computers so that software, hardware, and data files can shared
network
signed and dated
Using the ______ system, it is easy to locate misfiled charts VISUALLY with a quick glance
color coded system
What is the best measurement of the quality of care given to a patient
The medical record
medical records are the property of who?
the physician
an enormous computer network that links computers and smaller computer networks worldwide
the internet
The first section to be filled out using the SOAP method is _ , this information primarily comes from the_
Subjective section, the patient
In the medical office, how many main types of records are there?
4
It is currently estimated that _____ percent of medical offices have adopted and are using some form of an electronic health record system.
90%
The central responsibility of the physician's practice is
patient care
_____ computers have less power than mainframes.
mini
Style of record keeping that revolves around the patient's problem
POMR
A chronological record of ongoing patient care and progress is also known as
chart notes
What abbreviation means "after meals"?
pc
What method is the most common system for outlining and structuring chart notes for a medical record?
SOAP
files are kept in one place, either on a computer EHR or physical
centralized
Name the sections of the CHEDDAR Method
Chief Complaint
History of the present illness
Examination
Details of problems/complaints
Drugs and Dosage
Assessment
Return visit or refferal
Which type of files are arranged from left to right, instead of from front to back?
lateral files
Making corrections to a chart with an eraser or scribbling out entries could present the appearance of _______________.
fraud
Which charting format breaks down the components of a patient encounter into seven detail-oriented sections?
CHEDDAR
Another name for a central computer is ?
a file server
What is an SOMR
Source Oriented Medical Record
An accession book is used with which type of filing?
numeric