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Chapter 14 Vocabulary Medical Records Management

Medical Records Management

AB
Alphabetic filingany system that arranges names or topics according to the sequence of the letters in the alphabet.
alphanumericof or relating to systems made up of combinations of letters and numbers
audita formal examination of an organization's or individual's accounts or financial situation; a methodic examination and review.
augmentto make greater, more numerous, larger, or more intense
captiona heading, title, or subtitle under which records are filed
chronologic orderof, relating to, or arranged in or according to the order of time
continuity of carecontinuation of care smoothly from one provider to another, so that the patient receives the most benefit and no interruption in care
dictationthe act or manner of uttering words to be transcribed
direct filing systema filing system in which materials can be located without consulting an intermediary source of reference
gleanedgathered bit by bit e.g., information or material picked over in search of relevant material
indirect filing systema filing system in which an intermediary source of reference, such as a card file, must be consulted to locate specific files
microfilma film bearing a photographic record on a reduced scale of printed or other graphic matter
numeric filingthe filing of records, correspondence, or cards by number
objective informationinformation that is gathered by watching or observation of a patient
oblliterationact of making undecipherable or imperceptible by obscuring or wearing away
OUTfoldera folder used to provide space for the temporary filing of materials.
OUTguidea heavy guide that is used to replace a folder that has been temporarily moved from the filing space
power of attorneya legal instrument authorizing one to act as the attorney or agent of the grantor
pressboarda strong, highly glazed composition board resembling vulcanized fiber; heavy card stock
procrastinationthe intentional postponement of doing something that should be done
provisional diagnosisa temporary diagnosis made before all test results have been received
quality controlan aggregate of activities designed to ensure adequate quality, especially in manufactured products or in the service industries
requisitesentities considered essential or necessary
retention schedulea method or plan for retaining or keeping medical records, and their movement from active, to inactive, to closed filing
shelf filinga system that uses open shelves rather than cabinets for storing records
shinglinga method of filing whereby one report is laid on top of the older report, resembling the shingles of a roof
subjective informationinformation that is gained by questioning the patient or taken from a form
tickler filea chronologic file used as a reminder that something must be taken care of on a certain date
transcriptionto make a written copy of, either in longhand or by machine
vestedgranted or endowed with a particular authority, right, or property; to have a special interest in



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