medical records
How can medical records NOT be released?
CAN NOT be released without patient's knowledge. Patient has to have a signed release of information
where can you find a chief complaint in ?
Clinical section of the filing chart
What can you find in the filing chart?
Clinical section, correspondence, laboratory reports, progress notes and miscellaneous
What is the common used filing systems?
Alphabetic and Numeric
What are the three filing techniques?
Alphabetic, color coding and Subject filing
What are the basic rules for filing?
Alphabetizing is key to organize files and charts, rules facilitate alphabetic process in maintaining files, indexing units and filing patient charts
Where is color coding and alphabetically filing used at?
Ambulatory care and hospital systems
What does the medical record assists?
Assists in controlling costs of medical care
what is index uniting?
Each unit is identified ( last name, first name, and middle initial)
what does Soaper stands for?
Education for patient, response of patient to education and care given
What are the flow sheets for?
Flow sheets are used in the record to record on going measurements in a graph to table form
what does SOAP stands for?
Subjective, objective,assesment and plan
what is the purpose of referrals for medical records?
They are needed to provide referrals for specialty care
What does medical facilities generate of?
They generate a large amount of information
what are the 6 types of equipment and supplies?
Vertical files, Open shelf lateral files, movable file unit, file folders, identification labels and Out-guides
How is the medical record be released?
When it is subpoenaed by a court of law and when the doctor who created the record retires.
Release marks has?
providers initials and quality control measure
Filing chart data is?
the most common documents/types of reports in patient charts
what does it serve as?
it is serve as a basis for legal information necessary to protect providers, staff and patients.
Who developed the alphabetic filing?
it was developed by the Association of Medical records Administrators ( AMRA)
What is tickler files?
its used in calendar reminders and manual system. So it reminds us of an action that needs to be taken.
what does POMRs stands for?
problem oriented medical records`
what is least likely a single practitioners will used?
A manual or EMR
What is the purpose of accurate medical records?
Accurate medical records are essential for patient care.
what is CMA?
Credentialed Medical Assistants
when you do filing procedures, whats the number one thing you should do ?
Cross reference
What does HITECH means?
Health information technology for Economic and Clinical Health Act
if its not in the chart,
IT NEVER HAPPEN
What is the information?
Information that are in medical records of patients.
What is ownership of medical records
Is the property of physician creating the records
What is alphabetic filing?
Is when you use the patient's legal name. it's what the prefer name is on the chart
How do providers keep patients in their medical records?
Keeping foster trust and respect with their patients
What does the medical records maintain?
Maintains conscientious record of patient care
When is subject filing mostly used in?
Mostly used in business
Checkout systems are?
Out-sheets or out-guides. it list information that should be included on out-sheet
What should it contain?
Patient's name, tickler date when action should be taken, required action and additional relevant information
How to release information?
Patients must sign a release form if info is to be given to others.
What is it about?
To promote the adoption and meaningful use of health information technology and addresses the privacy and security concerns associated with the electronic transmission of health information.
Can it be used as an inlitigation?
Yes it can
Is the information safe?
Yes, it is protected by the privacy and confidentiality of HIPAA
Does it belong to the patient?
Yes, the information belongs to the patient
How to write a correction?
You ca nwrite Corr. or Correction above the area corrected
active filing is
a current patient files that need to be readily accessible
What kind of pen to use for corrections?
a red pen
how are identification labels used for?
adhered to the top or along side of the file folder
what are the vertical files?
cabinets that have pull drawers
For errors in EMR, you?
draw a line through the error
inactive file
files of patients that haven't been to the office between 2 to 3 or more years.
Closed files
files that are no longer required or needed
how are out guides use?
filling tool used to track a patient's chart that has been removed from the storage area
When filing patient's charts by alphabetic, you should?
have the roman numerals go first before junior and senior
What is CMA for?
is to enter medications, lab and radiology orders into computerized provider order entry ( CPOE) , systems for purposes of calculating meaningful use under the Medicare and medicaid Electronic health Records ( EHR) , incentive program
progress notes are?
is where info from phone calls and refills and documentation from patient encounters ( visits)
how does cross reference helps?
it helps stores files for quick and accurate retrieval and identify location of a file
What does POMR do?
it identifies problems numerically as listed by patients
What is the HIPAA Security rule for providers to set up an Electronic health information by law?
notify the patient and notify the Secretary of health and human services
what is out guides primarily do?
out guides primarily use is to indicate a chart has been removed
whats the information of the out guide?
primary information is who has possession of the chart
file folders should be..?
should be made of food quality card stock
When was it signed?
signed into law in 2009
record purging is
sorting through records and removing those not actively used
what are open shelf lateral files used for?
used to most often with color coded filing system
Is a medical record a legal document?
yes, the medical record is a legal information
