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21 Cards in this Set
- Front
- Back
Who is the owner of your medical records?
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Physician is the legal owner of the information in the medical records
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How do you get your medical records transferred?
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Only be released with a written release from the patient
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SOR
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Source Oriented medical Records
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POR
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Problem Oriented medical Records
** Most used by specialists |
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SOAP
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Subjective
Objective Assessment Plans |
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Chief Complaint
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Patients complaints or symptoms in their own words
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Obliteration
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of an entry in a medical record is never acceptable
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Closed files
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Patients who have died, moved away, or otherwise discontinued treatment
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How long should files be kept on a minor from the time they reach legal age?
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at least 3 years
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Continuity of Care
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Care continues smoothly from one provider to another, and the patient receives the best benefit
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POA
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*Power Of Attorney
**allowing one to act as the agent of the grantor |
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How long should you keep records on a deceased patient?
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at least 2 years
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Tickler file
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Follow up system used to help remember when a certain task needs to be done
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Indirect file system
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a system in which an intermediary source of reference, such as a file card, must be consulted to locate specific files
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Shingling
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method of filing where one report is laid on top of the older report, resembling a roof
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Indexing rules
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Last name, first name middle name or initial
**ex. Adams, John Mr. |
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Quality assurance
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Activities designed to increase the quality of a product through system changes
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Augment
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To make greater, more numerous or more intense
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Vested
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Granted or endowed with a particular authority
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Sentinel event
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a total power failure in a hospital
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nosocomial infection
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usually acquired in a hospital
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