The Importance of Medical Records
Contains important information about a patient's medical history and present condition
What is patient medical record (also known as charts)
The patient's record is not solely a medical document it is also which type of document.
What is a legal document
Specific information required of a population.
What is demographic information
Source Oriented Medical record also known as the conventional method
SOMR
Recording the patient's exact words
What are Client's words
Electronic format of medical records
What is Electronic Health Record (also known as Electronic Medical Records)
requires patient records be kept for 10 years.
What is the Federal False Claims Act
This part of the registration process includes illnesses, surgeries, known allergies, and current medications
What is patient Medical History
This method was developed by Lawrence L. Weed M.D. and makes it easier for the physician to keep track of the patient's progress.
Problem Oriented Medical Record (POMR)
Precise descriptions and accepted medical terminology when describing a patient's condition.
What is clarity
What does the abbreviation PHI stand for?
What is Personal Health Information.
The process of recording information in the medical record
What is Documentation.
What form is used for the review of systems (ROS)?
What is the physical examination form.
What does SOAP stand for?
What is Subjective, Objective, Assessment, and Plan
Brief and to the point
What is conciseness
Who owns the information contained in the medical record?
Who is the patient
What should the MA never insert into the patient record.
What is an opinion
Records from outside of the practice that must be included in the patient's medical record
What are documents from other sources.
An orderly series of steps for dealing with any medical case
What is SOAP
Entries should be dated to show the order in which they are made
What is chronological order
Who is responsible for making sure adequate patient records are prepared and available to meet the practice's needs?
Who is the medical assistant
What is the term used for a patient who does not follow the medical advice he/she is given?
What is noncompliant
What must be obtained when any procedure is being performed on a patient?
What is a consent form
Breaks the SOAP format into smaller components
What is CHEDDAR
Keeping patient's record/information private and protected
What is confidentiality