| A | B |
|---|
| Who owns the medical records | The physician or medical facility (the maker) is the owner of the Physical medical record, the patient have a right of access to the information in the record only. |
| POMR stands for | the problem oriented medical record |
| CBMR stands for | computer base medical record |
| Numeric Filing System | can be expanded without relocating all of the other files. |
| Hyphenated elements of a name in a filing | are treated as one unit: Carlotta Freeman-Duque (Freemanduque, Carlotta |
| Arranging papers in filing sequence is called | sorting |
| Active Files | are the files of patients who are currently receiving treatment |
| Three classifications of files | Alphabetic by name, Numeric and by Subject |
| For how many keeps the records in a non restriction state? | for a 10 year retention |
| Alphanumeric Filing System | in which combinations of letters and numbers are used to identify a file |
| Alphabetic Filing System | in which the letters of the alphabet are used to identify a file in order to arrange them. Need to know the correct spelling of a name, as the number of files increases, more space is needed, more time is required |
| Direct Filing System | provides patient confidentiality |
| Tickler File | a chronologic file that helps you remember that a certain action must be taken on a certain date. |
| Shingling | laying one report on top of another, with the most recent on top; |
| Subjective information | Information that is provided by the patient (routine personal data) or taken from a form like: Patient's full name, address, e-mail address, insurance information, gender, date of birth, marital status, spouse's name, # of children, SS, Driver's license, employer, Personal & Medical History: illnesses or surgical operations, explain injuries or physical defects, daily health habits, allergies. Patient's Family History: physical condition, illnesses and diseases of family members, family member's deaths. Patient's Social History: lyfestyle, alcohol, tobacco, drug, marital and pshychologic information, emotional too. Patient's chief complaint: nature and duration of pain, symptoms, patient's opinion as to the possible causes, remedies has tried, past medical treatment for the same condition. |
| Objective information | Information that is gathered by physical examination or observation of a patient and laboratory & Radiology Reports, diagnosis, treatment prescribed, progress notes, condition at the time of termination of treatment, others: Yellowed eyes, elevated blood pressure, bloated stomach, weight of 143 lb, bruises on upper arms |
| Color-Coded files | keeps patient charts in order and swiftly locate them when are misfiled, makes the files quick and easy |
| reasons that medical records exist | medical records provide statistical informaion, are vital for financial reimbursement, offer legal protection for doctors. |
| Two major types of patient records | The paper-based medical record and the computer-based medical record |
| Can a record be released? | Records can not be released without the express permission of the patient by signing a release form |
| How you request a release of medical information? | should be request in writing, no fax is accepted, even the power of attorney document has to be signed by the patient |
| Original case histories can not be released | Instead, photocopy or prepare a summary |
| some physicians release case histories to their colleagues or original record has to be send to court | In such instances, a colored OUTfolder should be inserted in the file and a notation made of the name, date, and to whom the record was released, until the original is returned. |
| Inactive files | are those of patients whom the doctor has not seen for 6 months or longer. |
| Closed files | are records of patients who have died, moved away, or terminated their relationship with the physician |
| Retention of Records | When no restriction exists, it is best to keep the records for a 10-year period, for a minor until reaches the majority age plus an additional 3 years. In all cases, medical records should be kept for at least 3 or more years or as long as the length of time of the statute of limitations for medical professional liability claim |
| Retention of Records by Medicare or Medicaid | must be kept at least 6 years |
| Retention of Records for death patients | HIAA recommends to keep records for at least 2 years. |
| Before old records are discarded | patients should be given an opportunity to claim a copy or have them sent to another physician |
| When discarding old records | destroyed them by shredding or though a professional destruction service. |
| Revocation Form | When a patient no longer wishes to allow his or her medical records to be released to a person or organization |
| Direct Filing System | materials can be located without consulting an intermediary source of reference. |
| Indirect Filing System | a filing system in which an intermediary source of reference, such as a card file, must be consulted to locate specific files. |
| OUTfolder | a folder used to provide space for the temporary filing of materials. |
| OUTguide | a heavy guide that is used to replace a folder that has been temporarily moved from the filing space. |
| procrastination | the intentional postponement of doing something that shosuld be done |
| vested | to have a special interest in, |
| Five basics filing steps | Conditioning of papers, Releasing indicating that is ready for filing, Indexing and coding, sorting (arranging), storing and filing. |
| SOAPE | Subjective (impressions), Objective (clinical evidence), Assesment (or diagnosis), Plans (further studies, treatment or management), Evaluation |
| Patient's Chief Complaint | is a concise account of the patient's symptoms explained in the patient's own words: nature and duration of pain, time when the patient first noticed sysmptoms, patient's opinion, remedies, other medical treatment received. |
| HIPAA | The Health Insurance Portability and Accountability Act |
| The apostrophe in filing | is disregarded: Anderson's surgical supply (Andersons Surgical supply) |
| When indexing a foreign name | index each part of the name in the order in which it is written, unless you can make the distinction: Cau Liu (Cau Liu) |
| Names with prefixes | are considered as part of the name: Von Schmidt (Vonschmidt), De Long (Delong) |
| Abbreviated parts of a name | are indexed as written altogether: Ste. Marie (Stemarie), St. John (Stjohn), Wm. (Wm), Edw. (Edw), Jas. (Jas) |
| Mac and Mc are filed | in their regular place in the alphabet |
| the name of a married woman | is indexed by her legal name (her husband's surname), her given name, and her middle name: Mrs. John L. Doe (Mary Jones), Doe, Mary Jones (Mrs. John L.). |
| Title when followed by a complet name should be filed: | as the last filing unit to distinguish from another identical name: Mr. James D. Conley (Conley, James D Mr.), Dr. James sD. Conley (Conley, James D Dr.) |
| Titles without complete names | are considered the first indexing unit: Madame Sylvia, Sister Theresa |
| Terms of seniority, or professional or academic degree | Theodore Wilson, M.D. (Wilson, Theodore (M.D.), Lawrence W. Sloan, Jr. (Sloan, Lawrence W. (Jr.), Lawrence W. Sloann, Sr. - Sloan, Lawrence @. (Sr.) |
| Articles such as "The and "A" | are disregarded in indexing: The Moore Clinic - Moore Cllinic (the) |
| Why medical records are important | Assist theh physician in providing the best possible care to the patient. Offer legal protection to those who provide care to the patient. Provide statiscal information that is helpful to researches. Vital for financial reimbursement. |
| To create an efficient Medical Record System, the system should: | provide for easy retrieval, be organized and orderly, contain information that is completely legible, contain accurate inforamtion, show information that is easily understood and grammatically correct. |
| Obtaining History of the patient | A combination of questionnaire and questions by the MA or Physician |
| Making additions to the record | place the most recent information on top, physicians should read and initial reports before they are filed, follow the office policy. |
| Radiology Reports | Usually typed on standard sized stationary. Place in reverse chronologic order with the most recent report on top |
| Progress Notes | Continually added to the medical record, must list each patient visit and any notationss about the visit, always initial entries. |
| Making corrections & alterations to Medical Records | Never use correction fluid, eraser, do not mark through information to obliterate it, do not hide errors, bring it to the physician's attention immediately |
| Three steps to correct an error | Draw one line through the error, insert the correction above or immediately after the error, In the margin write correction or Corr., the initial of the person correcting the entry, and the date. |
| Correcting electronic Records | if an error is made when typing., simply backspace and correct the error, if the error is discovered later, make an additional entry with corrected information, do not delete or change it. |
| Releasing medical record information | Requests must be made in writing for release of records. Patients, must sign an authorization for release of medical records. Patients can revoke previously signed authorizations for release of records. Release only records that are specified on the request. |
| Disadvantage of paper-based medical records | only one person can se the record at a time, items can be easily lost or misfiled or can slip out of the record if not securely fastened. |
| Advantages of computer-based medical records | more than one person can use the record at a time, information can be accessed in a variety of physicial locations, records can often be accessed from another city or state, complete informationis often available in emergency situations. |
| Database includes: | chief complaints, present illness, patient profile, review of systems, physical examination, laboratory reports |
