| A | B |
|---|
| SOAP notes | progress note |
| autopsy report | determines cause of death |
| phone, visit or email contacts | need to be documented |
| subjective info | what pt feels, why visit doctor |
| Mac and Mc | file by office's preference |
| tickler file | reminds of upcoming events or action |
| cross reference | referring to another possible choice |
| physician owns record | "privileged communication" legal right of pt record |
| 2 year statute of limitations | runs at point of discover of damage and tx |
| 7 | length to store medical records |
| incident report | document problems |
| closed records | archives |
| divider guides | separate files |
| operative report | surgical procedure report |
| documentation | should be objective |
| straight numberic filing | simplest numerical file system |
| subject matter | general filing for invoices, resumes, records |
| POMR | problem oriented medical record |
| POMR sheet | kept at front of chart |
| Back up systems | run daily |
| Paper Record | usually shred after entering EMR |
| telephone msg | can send electronic or hard copy |
| EMR | saved on hard drive or network |
| back up system | run daily in medical office |
| Paper or EMR | both have same info |
| Scanned into EMR | shred original |
| paper based charts | start day b4 |
| 1960's | Mayo Clinic began using EMR |
| family members record | only on a nn to know if do so notify supervisor |
| drop down menu | list of items to choose, ei DX codes symptons |
| EMR tracking | who accessed, charting, multiple user views use passwords to access |
| 2014 | EMR will be in effect |
| PDA | help physician with work |
