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Flashcards in Information Management Deck (298):
1

Computer

Electronic device that receives, manipulates, and stores data.

2

Computer Classification

According to size: Generally, larger computers have greater storage capacity and faster processing times.
- Supercomputer
- Mainframe
- Minicomputer
- Microcomputer

3

Supercomputer

Large, complex computer system capable of performing rapid, complex functions, such as national defense and weather forecasting and research.

4

Mainframe

Large computer capable of handling hundreds of users.

5

Minicomputer

Medium-sized computer that can handle multiple users.

6

Microcomputer

Desktop personal computer (PC).

7

Hardware

Physical computer equipment.

8

Central processing unit (CPU)

Collection of three components that process data.
- Control Unit (CU)
- Arithmetic logic unit (ALU)
- Primary storage unit (PSU)

9

Control unit (CU)

It doesn't perform the actual data processing, it supervises the data processing operations. The CU performs the following:
- Retrieving: obtains instructions from the primary storage unit.
- Decoding: translate the instructions into language the computer understands.
- Executing: carries out the instructions.
- Storing: Results of the instructions are stored in the primary storage unit (PSU).

10

Control Unit- Retrieving

Retrieving:
- Obtains instructions from the primary storage unit.

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Control Unit- Decoding

Decoding:
- Translate the instructions into language the computer understands.

12

Control Unit- Executing

Executing:
- Carries out the instructions.

13

Control Unit- Executing

Executing:
- Carries out the instructions.

14

Control Unit- Storing

Storing:
- Results of the instructions are stored in the primary storage unit (PSU).

15

Arithmetic Logic Unit (ALU)

Processes the data in two ways.
- Arithmetic operations
- Logic operations

16

Arithmetic operations

Mathematical calculations involving addition, subtraction, multiplication and division.

17

Primary Storage Unit (PSU)


Main computer memory that stores data and program instructions.
- Random access memory (RAM)
- Read only memory (ROM)

18

Primary Storage Unit (PSU)

Main computer memory that stores within the CPU that is lost once power is discontinued.

19

Random Access Memory (RAM)

Temporary memory within the CPU that is lost once power is discontinued.

20

Random Access Memory (RAM)

Temporary memory within the CPU that is lost once

21

Read Only Memory (ROM)

Permanent memory within the CPU installed by the manufacturer that allows the computer to carry out its operations.

22

Input devices






Allows for the input of data into a computer.
- Keyboard
- Mouse
- Trackball
- Joystick
- Digitalized tablet
- Light pen (wand)
- Scanners

23

Input devices-

Keyboard:
- Allows for the input of alphanumeric data.

24

Input devices- Keyboard

Keyboard:
- Allows for the input of alphanumeric data.

25

Input devices- Mouse

Mouse:
- Handheld device that, when moved across a flat surface, moves the cursor to any spot on the monitor screen.

26

Input devices- Trackball

Trackball:
- A ball embedded in the base when rolled, moves the cursor on the screen.

27

Input devices- Joystick

Joystick:
- A vertical stick embedded in a base that moves the cursor in the direction the stick is moved.

28

Input devices- Digitalized tablet

Digitalized tablet:
- A pressure sensitive pad that produces on the screen any outline drawn on the pad.

29

Input devices- Light pen (wand)

Light pen (wand):
- A pen that is sensitive to the light emanating from the screen. When placed close to the screen, it can control the cursor and activate various functions.

30

Output devices


Allows for data to be displayed or recorded.
- Monitor
- Printer
- Plotter

31

Output devices

Allows for data to be displayed or recorded.
- Montior
- Printer
- Plotter

32

Output devices- Monitor

Monitor:
- Cathode ray tube (CRT) or screen that visually displays data.

33

Output devices- Printer

Printer:
- A device that records data on hard copy (paper).

34

Ports

Means of connecting peripheral to the CPU.
- Serial port
- Parallel port.

35

Ports

Means of connecting peripheral to the CPU.
- Serial port
- Parallel port.

36

Serial port

Sequentially transfers data on one piece at a time.

37

Parallel port

Transfers groups of data at a time.

38

Secondary storage

Due to the temporary nature of RAM in the primary storage unit, it is necessary to use secondary storage components to store data and programs.
- Hard disk
- Floppy disk
- Disk drive
- Magnetic tape
- Optical disks
- Solid-state devices

39

Secondary storage- Hard disk

Hard disk:
- Internally contained magnetic disk for data and program storage.

39

Secondary storage- Hard disk

Hard disk:
- Internally contained magnetic disk for data and program storage.

40

Secondary storage- Floppy disk

Floppy disk:
- External magnetic disk, that, when inserted into a disk drive, can store and load data and programs.

41

Secondary storage- Disk drive

Disk drive:
- Electronic device that retrieves and stores data on a diskette.

42

Secondary storage- Magnetic tape

Magnetic tape:
- Magnetic cassette tape or reel used to store data and programs.

43

Secondary storage- Optical disks

Optical disks:
- DVD's (digital Video Disks) and CD's (Compact Disks). Data is stored on a metal surface that can be read by a laser.

44

Secondary storage- Solid-state device

Solid-state device:
- Small (size of a thumb or car key) removable storage/memory cards that have no moving parts. They plug into a USB port on the computer, and have various names depending on the manufacturer (e.g., flash drive, flash pen, thumb drive, key drive and mini-USB drive.

45

Software

A computer program that provides processing instructions to the computer.
- System software
- Application software

46

Data Processing- Transforming data into a useful information

- Data: Raw information such as numbers and letters that the computer processes.
- Information: Processed data that can be used in a meaningful way.

47

Data Processing


- Transforming data into a useful information
- Memory
- Machine language
- Data processing cycle

48

Data Processing

Transforming data into useful information.
- Data: Raw information such as numbers and letters that the computer processes.
- Information: Processed data that can be used in a meaningful way.

49

Data Processing- Memory-
"Bit"

Bit:
- Binary digit. Smallest piece of information processed by a computer.
- When an electrical charge is absent, the bit is off and takes the binary value 0.

50

Data Processing- Memory

Memory:
- Bit
- Byte
- Kilobyte (K)
- Megabyte (M)

51

Data Processing- Memory-
"Bit"

Bit:
- Binary digit. Smallest piece of information processed by a computer.

52

Data Processing- Memory-
"Byte"

Byte:
- An 8-bit unit. One byte of memory is required to represent a character.

53

Data Processing- Memory-
"Kilobyte"

Kilobyte:
- Represents 1024 bytes.

54

Data Processing- Memory-
"Megabyte"

Megabyte:
- Represents 1000 kilobytes.

55

Machine language

Binary computer coding system that represents each data character.

56

Machine language- ASCII

ASCII: American Standard Code for Information Interchange.
- A machine language used in many microcomputers.

57

Machine language- EBDIC

EBCDIC: Extended Binary Coded Decimal Intercharge Code.
- A machine language used by larger computers.

58

Data processing cycle

-Input: Data is entered into a computer via an input device.
- Processing: Manipulation of the data that has been inputted.
-Output: After the data is processed, resulting information can be accessed via an output device.
- Storage: Input or output data or information is stored on a storage medium such as a floppy disk .

59

Booting

Process of activating the input of the operating system into a main memory.

60

Program installation

Process of loading the software instructions onto the hard disk of the computer. Specific installation instruction are included with the software package.

61

Disk formatting

Process of organizing a blank disk into sectors so that it can store data.

62

Disk copy


Process of copying a file on a diskette or copying the contents of an entire diskette onto a second diskette, especially backup copies.

63

Configuration

Disk drive arrangement.

64

Bus

Any path that data travels inside the computer.

65

Buffer

Location for temporary data storage during computer processing.

66

Bus

Any path that data travels inside the computer.

67

Clipboard

A section of computer memory used to temporarily hold data that has been cut or copied for transfer to another document or location within a document.

68

Data compression

Program that forces data into less space on the storage medium.

69

Glidepad

Touch-sensitive pad for controlling cursor motion. Common on laptops.

70

Megahurtz MHz

1 million cycles per second.

71

Network

A set of computers that are permanently linked together.

72

Node

Each device connected to a network.

73

OCR software

Software that changes a scanned document from an image to editable text-- commonly used for insurance claims.

74

Personal Data Assistant (PDA)

Small personal computer with limited capabilities.

75

Point size

Measures the height of letters where 1 point is 1/72 inch.

76

Query

A way to arrange records in a particular kind of order or to show only the records that match certain criteria.

77

Queue

The set of print jobs waiting to be done.

78

Server

A computer that handles network tasks.

79

Suite

A set of separate applications that are packaged together usually at a lower price than they would cost separately, e.g., Microsoft Office Suite.

80

Tower

Vertical case for a personal computer.

81

Word processing functions- Formatting

Formatting:
- Determines the physical layout of a document.
- Margins
- Tab set
- Line spacing
- Pitch

82

Word processing function- Formatting
"Pitch"


Pitch:
Sets the number of characters per inch of text.
- Pica: 10 characters per horizontal inch.
- Elite: 12 characters per horizontal inch.

83

Word processing functions- Formatting
"Widow/Orphans"

Eliminates a window or orphan.
- A widow is the last paragraph line appearing alone at the top of the page.
- An orphan is the first paragraph line appearing alone at the bottom of a page.

84

Word processing functions- Formatting
"Retrieval"

Acquiring from storage, data, or information that has been saved on a disk.

85

Word processing functions- Formatting
"Justification"

Determines the alignment of text relative to the left or right margin.

86

Word processing functions- Formatting
"Header/Footer"

Prints identical information at the top or bottom of each page.

87

Word processing functions- Formatting
"Pagination"

Positions and prints page numbers.

88

Word processing- Editing
"Block"

Using the cursor, text can be highlighted for manipulation.

89

Word processing functions- Window

An application that allows more than one application to be operational at one time.

90

Word processing- Sort

Organize a list alphabetically or numerically in ascending or descending order.

91

Word processing functions- Desktop publishing

Document presentation tool that permits the production of professional documents containing both text and graphics.

92

Spreadsheets- Numbers productivity tool

- Software programs that permit rapid calculations applied to a table of numerical data.

93

Sort

Organize a list alphabetically or numerically in ascending or descending order.

94

Desktop publishing

Document presentation tool that permits the production of professional documents containing both text and graphics.

95

Spreadsheets- Numbers productivity tool

- Software programs that permit rapid calculations applied to a table of numerical data.
- Worksheet: Working document that contains empty rows and columns for the input of data that can be numerically manipulated.

96

Spreadsheet- Worksheet



Worksheet: Working document that contains empty rows and columns for the input of data that can be numerically manipulated.
- Columns headings are alphabetical.
- Row headings are numerical.
- Cell: intersection of a row and column; e.g., cell A1 represents the space occupied at column A, row 1.

97

Spreadsheet- Data forms

the following types of data can be entered in a cell.
- Labels: Alphanumeric characters usually used as headings to identify the row or column.
- Numerical data to which calculations can be applied.
- Formulas: Provide instructions for performing a mathematical calculation on data entered in other cells.

98

Spreadsheet- Formula symbols

- Addition +
- Subtraction -
- Multiplication X
- Division /
- Exponents ^

99

Spreadsheet- Order of operations




When entering a formula, certain mathematical tasks will be carried out in a specified order. Calculations will be performed from left to right with parentheses first, then exponents, multiplication and division, and finally addition and subtraction.

100

Spreadsheet- Special functions

- @SUM: Will add a group of values.
- @AVG: Will average a group of values.
- @SQR: will determine the square root of a value.

101

Spreadsheet- Range

A designated group of cell sbeing affected by a calculation or task; e.g., (A1..C5) indicates that the task at hand should be applied to cells A1, A2, A3, through A15, B1, B2, through B15, C1, C2, C4, and C5 only.

102

Data hierarchy- Records & Files





- Fields: Basic piece of data such as a name, address, or course grade; usually arranged in columns.
- Records: Collection of related fields, usually arranged in rows. Each record within a file will have the same collection of fields.
- Fields: Collection of related records.

103

Database- Data management tool

Software programs that facilitate the collection of data files that can be accessed, manipulated, rearranged, sorted and categorized to meet users information needs.

104

Database- Data hierarchy







- Fields: Basic piece of data such as a name, address, or course grade; usually arranged in columns.
- Alphanumeric: Data using any combination of letters, numbers, or symbols.
- Numeric: Numerical data used as codes or for calculations, or to express quantity.
- Logical: Data having one of two possible conditions; yes/no, male/female, true/false, etc.

105

Data hierarchy- Records & Files

- Records: Collection of related fields, usually arranged in rows. Each record within a file will have the same collection of fields.
- Fields: Collection of related records.

106

Database- Entry operations
"Additions"






Adding a field, record, or file to a database.
- Ascending: Adding data at the end of a data set.
- Inserting: Adding data between data sets.
- Deletion: Removing a field, record, or file from a database.
- Modification: changing an existing field, record or file.

107

Database- Detail reports

Detail reports:
- Reports that list the records in each file.

108

Medical Practice Software










1. Handles appointment scheduling, billing, and collection.
2. The data contains demographic, financial and insurance information.
3. Each new patient's information is added to the database.
4. Codes the service to system can generate a claim for a third party payer or for the patient.
5. Can fun financial reports.
6. May include a code-checker to prevent improper coded claims.

109

Database report- Exceptional report



Exceptional report:
- Reports that identify fields or records that have a unique characteristic; commonly describes data that falls outside the norm or predetermined data set.

110

Database- Det ail reports

Detail reports:
- Reports that list the records in each file.

111

Medical Practice Software










1. Handles appointment scheduling, billing, and collection.
2. The data contains demographic, financial and insurance information.
3. Each new patient's information is added to the database.
4. Codes the service to system can generate a claim for a third party payer or for the patient.
5. Can fun financial reports.
6. May include a code-checker to prevent improper coded claims.

112

Medical Practice Software- E-prescribe

E-prescribe:
- Provides reminders and alerts, and promotes compliance with guidelines and formularies.

113

Medical Practice Software- Planning and implementation of information technology (IT)

1. considered the future of medical decision-making.
2. Information offers tools, not solutions.
3. The success or failure of IT applications is related to change management.
4. Treat IT decision as cyclical
5. Educate and train your staff on IT
6. IT application are dependent on people.
7. Don't try to do everything yourself.

114

Medical Practice Software- Consideration

1. Needs and wants.
2. Time frame for the IT applications.
3. Who will be responsible?
4. What process will you use to evaluate your options and make a decision?
5. How will you evaluate the results of your purchase.

115

Medical Practice Software- Steps









1. HIPAA Security Rule Compliance.
2. Set goals and priorities.
3. Create a task force.
4. Develop a practice profile.
5. Identify and solicit vendors.
6. Compare rank vendors responses.
7. Make site visits and check references.
8. Select the vendors and sign agreements.
9. Develop an implementation plan.
10. Evaluate the results.
11. Start again.

116

Medical Practice Software- Keys to success






1. Identify a champion who is able and willing to coach others through the transition process.
2. Enlist the commitment of all physicians in the practice.
3. Plan the timing to suit practice needs.
4. Retain control of training and transition.
5. Purchase an adequate level of support.

117

Data Communications

- Connectivity tool
- Transfer of data from one point to another such as between computers in a room, or over long distances.

118

Data Transmissions

- Movement of data across communication lines.
- Serial transmission
- Parallel transmission
- Asynchronous
- Synchronous transmission
- Simplex
- Half duplex
- Full duplex

119

Serial transmission

Data is transmitted one bit at a time sequentially.

120

Parallel transmission

All bits in a byte are transmitted simultaneously.

121

Asynchronous

Bytes are transmitted one at a time.

122

Synchronous

Bytes are transmitted in groups.

123

Simplex

Data is transmitted in one direction only.

124

Half duplex

Data can be transmitted to and from the point of origin, but only one direction at a time.

125

Full duplex

Data can be transmitted in both directions simultaneously.

126

Modem

Hardware component known as a modulator-demodulater that connects computers to communication lines.

127

Networks

Collection of terminals, computers and other equipment that uses communication channels to share data, information, hardware, and software.
- Local Area Network (LAN)
- Metropolitan Area Network (MAN)
- Wide Area Network (WAN)

128

Integrated software

- Combination productivity tool.
- Software package that combines applications such as word processing, spreadsheet, database, desktop publishing, and data communications programs to offer a powerful and flexible data processing tool.

129

MAN

Metropolitan Area Network:
- Privately owned communication network that covers a large citywide operation.

130

WAN

Wide Area Network:
- Communication network that are privately or publicly owned covering a wide geographic area through the use of telephone lines, microwaves, and satellites.

131

Integrated software

Combination productivity too. Software package that combines applications such as word processing, spreadsheet, database, desktop publishing, and data communications programs to offer a powerful and flexible data processing tool.

132

Computer crime- Salami shaving

A form of computer embezzlement diverts small amounts of money from private accounts into one's account.

133

Computer crime- Software piracy

Illegally acquiring and using computer software (bootleg software) in violation of copyright laws. Site licensing generally must be purchased to copy software for multiple users in an organization.

134

Computer crime- Computer embezzlement

Using computer technology to illegally divert funds.

135

Salami shaving

A form of computer embezzlement diverts small amounts of money from private accounts into one's account.

136

Computer crime- Time bombs

Computer programs that are designed to erase files or compromise data.

137

Computer crime- Data diddling

Changing data for one's own benefit; e.g., credit reports.

138

Computer crime- Trojan horse/trap door

A computer program designed to acquire access codes and passwords for illegal entry into a computer system.

139

Computer crime- Computer virus

A program created by another computer user that adversely affects the integrity of data or proper functioning of identity theft.

140

Electronic Communications Privacy Act of 1986

Protects against illegal interception of data communications.

141

Medical Records- Electronic Health Record (EHR)

1. Complex system of coordinated hardware, software, people, policies, and processes in support of patient care.
2. The ideal EHR system will capture data from multiple sources and used at a point-of-care (POC) to support clinical decision-making.

142

A fully realized EHR system will provide

1. Seamless information interchange among providers at all levels of the health care continuum.
2. Support for fully integrated evidence-based medicine.
3. Embedded medical terminology to assist with documentation.

143

EHR Benefits

1. Provide documentation of clinical findings and procedures.
2. Active reminders for medication administration.
3. Protocols for medical procedures.
4. Combined scheduling, registration, and billing system.
5. Data and information can be exchanged with other providers and system.
6. CCR: Continuity of Care Records: Standards content physicians agree should be in a referral.

144

CCR

Continuity Of Records

145

EHR

Electronic Health Records

146

EHR Technology-

- Databases
- Data exchange
- Images
- Workflow systems
- Data retrieval
- Data capture technology
- System communications and networks
- Storage technology
- Workstation

147

EHR Technology- Databases

Databases:
- Organized collection of data in standardized format

148

EHR Technology- Data capture technology

Data capture technology:
- Human-computer interfaces; e.g. templates, macros, speech/handwriting recognition, handheld/wireless devices, patient devices, etc.

149

EHR Technology- Images

Images:
- Electronically store and view documents and clinical images.

150

EHR Technology- Workflow systems

Workflow systems:
- Any work process that must be handled by more than one person. Allowing access to the same information by multiple users.

151

EHR Technology- Data retrieval technology

Data retrieval technology:
- Viewing data in a flexible format.

152

EHR Technology- Data capture technology

Data capture technology:
- Human-computer interfaces; e.g. templates, macros, speech/hand-writing recognition, handheld/wireless devices, patient devices, etc.

153

EHR Technology- System communication and network

System communication and network:
- Hardware and architecture, LAN, WLAN and WANs.

154

EHR Technology- Storage technology

Storage technology:
- Capable of archiving enormous amounts of data that can be retrieved in real-time.

155

Health Care Data Sets- Data set

Data set:
- List of recommended data elements having uniform definitions.

156

Health Care Data Sets- Common Data Sets



















Common Data Sets:
- Uniform Hospital Discharge Data Set (UHDDS): Inpatient hospital care.
- Uniform Ambulatory Care Data Set (UACDS): Care provided to patient who return home on day of service.
- Minimum Data Set for Long-Term Care (MDS): Nursing home residents.
- Outcome and Assessment Information Set (OASIS): Medicine beneficiaries receiving services from a home health agency.
- Data Elements for Emergency Department Systems (DEEDS)
- Essential Medical Data Set (EMDS): complements DEEDS; concise medical history data set for each patient.
- Health Plan Employer Data and Information Set (HEDIS):
- Provides consumer with information needed to compare the performance of managed care plans.

157

Health Care Data Sets- Common Data Sets
"Uniform Hospital Discharge Data Set (UHDDS)"

Uniform Hospital Discharge Data Set (UHDDS):
- Inpatient hospital care.

158

Health Care Data Sets- Information

Information:
- Data has been collected, combined, analyzed, interpreted, and/or converted into a form that is meaningful.

159

Health Care Data Sets- Data set

Data set:
- List of recommended data elements having uniform definitions.

160

Health Care Data Sets- Common Data Sets



















Common Data Sets:
- Uniform Hospital Discharge Data Set (UHDDS): Inpatient hospital care.
- Uniform Ambulatory Care Data Set (UACDS): Care provided to patient who return home on day of service.
- Minimum Data Set for Long-Term Care (MDS): Nursing home residents.
- Outcome and Assessment Information Set (OASIS): Medicine beneficiaries receiving services from a home health agency.
- Data Elements for Emergency Department Systems (DEEDS)
- Essential Medical Data Set (EMDS): complements DEEDS; concise medical history data set for each patient.
- Health Plan Employer Data and Information Set (HEDIS):
- Provides consumer with information needed to compare the performance of managed care plans.

161

Health Care Data Sets- Common Data Sets
"Uniform Hospital Discharge Data Set (UHDDS)"

Uniform Hospital Discharge Data Set (UHDDS):
- Inpatient hospital care.

162

Health Care Data Sets- Common Data Sets
"Uniform Ambulatory Care Data Set (UACDS)"

Uniform Ambulatory Care Data Set:
- Care provided to patient who return home on day of service.

163

Health Care Data Sets- Common Data Sets
"Minimum Data Set for Long-term Care"

Minimum Data Set for Long-Term Care:
- Nursing home residents.

164

Health Care Data Sets- Common Data Sets "Outcome and Assessment Information Set (OASIS)

Outcome and Assessment Information Set (OASIS):
- Medicare beneficiaries receiving services from a home health agency.

165

Health Care Data Sets- Common Data Sets "Data Elements for Emergency Department Systems (DEEDS)"

Data Elements for Emergency Department Systems (DEEDS):
- Essential Medical Data Set (EMDS): Complements DEEDS; concise medical history data set for each patient.

166

Health Care Data Sets- Common Data Sets "Health Plan Employer Data and Information Set (HEDIS)"

Health Plan Employer Data and Information Set (HEDIS):
- Provides consumers with information needed to compare the performance of managed care plans.

167

Records Management-

System of classifying, arranging and storing documents in an orderly, efficient\, and easily accessible manner.

168

Records Management- Out guide

Out guide:
- A guide used to replace a chart that has been temporarily removed from the cabinet, identifying the location or person in possession of the record.

169

Records Management- Common storage media

- Hardcopy
- Microfiche/microfilm
- Computer

170

Records Management- Equipment and supplies

Storage cabinet:
- Vertical: File cabinet style
- Lateral: Chest of drawers style
- Shelf:
1. Open or closed
2. Stationary or pullout shelves

171

Records Management- Guides

- Out guide: A guide used to replace a chart that has been temporarily removed from the cabinet, identifying the location or person in possession of the record.
- Out folder: A folder that serves as an out guide but can hold patients documents temporarily until the medical record is returned.

172

Records Management- Out guide

Out guide:
- A guide used to replace a chart that has been temporarily removed from the cabinet, identifying the location or person in possession of the record.

173

Records Management- Out folder


Out folder:
- A folder that serves as an out guide but can hold patients documents temporarily until the medical record is returned.

174

Records Management- Folders

Folders:
- Cardboard or plastic holders that contain a file's documents. Folders are often equipped with tabs to aid in the identification of their concerns.

175

Records Management- Labels


Labels:
- Small stickers affixed to folders, drawers, and shelves to identify their contents.

176

Records Management- Alphabetical indexing rules

A person's name is indexed with the surname as unit 1, the given name as unit 2, and the middle name as unit 3. A fourth unit, usually date of birth is used fro identical names.

177

Records Management- Alphabetical indexing rules

Initials comes before complete names starting with the same letter.

178

Records Management- Alphabetical indexing rules

Units having no names come before those that do (nothing come before something).
- Able W. A.
- Able Warren Seth

179

Records Management- Alphabetical indexing rules

A hyphenated name is considered a single unit, e.g. Michael-Smith is indexed Michaelsmith. And the hyphen is disregarded unless it is a business name; in this case, they are placed in separate units at the hyphen.

180

Records Management- Alphabetical indexing rules

Apostrophes in a name are disregarded, e.g. O'brian is indexed as Obrian.

181

Records Management- Numerical filing

- Each patient is assigned a number that is identified on their medical chart.
- Each patient's number is cross-referenced with the patient's name and filed alphabetically.
- Commonly used in hospitals, group practices, and large clinics.

182

Records Management- Alphabetical indexing rules

Abbreviations are indexed as if written in full., e.g. Wm is indexed William.

183

Records Management- Alphabetical indexing rules

Numbers as part of a name are indexed as if written out. e.g., 4th is indexed fourth.

184

Records Management- Alphabetical indexing rules

Titles, degrees, and terms for seniority usually are not condiere4d in filing but may be indexed last, or may be placed in parenthesis at the end of the name for identification purposes, e.g., Dr., Pastor, Professor, Ph.D., M.S., B.S., A.S., Sr., Jr., I., II., III.

185

Records Management- Numerical filing

- Each patient is assigned a number that is identified on their medical chart.
- Each patient's number is cross-referenced with the patient's name and filed alphabetically.
- Commonly used in hospitals, group practices, and large clinics.

186

Records Management- Consecutive numerical system

Each patient is assigned a number in the order of their first visit.

187

Records Management- Terminal digit system

- Patients are assigned consecutive numbers as they visit the clinic.
- The numbers are separated into groups of two or three.
- Individual #
- Secondary #
- Primary #

188

Records Management- Terminal digit filing

Index by primary number in ascending order. Then by secondary number in ascending order. Finally by to individual number in ascending order.

189

Records Management- Subject filing

Documents are indexed according to geographic location.

190

Records Management- Geographic filing

Documents are indexed according to geographic location.

191

Records Management- Phonetic filing

Records are filed according to the sound of names rather than on spelling. Consonant sounds are assigned a code number and filed accordingly.

192

Records Management- Electronic filing

- Bar codes: Medical records may be labeled with bar codes that can be read and tracked by computer software.
- Scanners: Scanning devices may be used to scan and index insurance documents and the like.
- Databases: Electronic files that can be accessed according to some search criteria.

193

Records Management- Color coding

- Colored tabs may be employed to represent information about a chart or a patient at a glance.
- Most color coding system are used on letters of the patient's surname to identify misfiled charts.

194

Records Management- Tickler file

A general filing system that organizes items chronologically for follow-up such as appointments accounts payable due dates, or insurance tracking.

195

Mail Processing- Quality control

Scale can be quality controlled by verifying that nine pennies equal 1oz.

196

Mail Processing- Postage meter

Machine used to print prepaid postage directly on envelopes or adhesive strips. May be used for any class of mail.

197

Mail Processing- Rubber stamps

To indicate date of receipt and to place restrictive endorsement of checks.

198

Mail Processing- Tracing mail

Mail that has not reached its destination can be traced by completing a postal form.

199

Mail Processing- Recalling mail

If mail has been sent in error, it may be returned if the mail has not been delivered to the recipient.

200

Mail Processing- Incoming mail

- Mail inadvertently opened should be resealed with tape with a notation indicating it was opened in error.
- All checks received should be immediately stamped with a restrictive endorsement.

201

Mail Processing- Fourth class

Parcel post. Delivery of packages and printed materials weighing 1 to 70lb within specified physical dimensions (108 inches). postage depends on weight and destination.

202

Mail Processing- Mixed class

Delivery of a letter sent with a parcel.

203

Mail Processing- Special fourth class

Delivery of books and manuscripts that have a minimum of 24 pages of which at least 22 must be text or illustrations without any form of advertising.

204

Writing Mechanics- Verb

Verb:
- A word that describes an action, or limits a noun-- tells you something about the noun.

205

Writing Mechanics- Adjective

Adjectives
- A word that describes or limits a noun-- tells you something about the noun.

206

Mail Processing- Mail log

An incoming and outgoing log may be established to record daily mail activity.

207

Writing Mechanics- Noun

Noun:
- A word that names a person, place, thing, idea, living creatures, quality or action.

208

Writing Mechanics- Verb

A word that describes an action, or limits a noun-- tells you something about the noun.

209

Writing Mechanics- Adjective

Adjectives:

210

Writing Mechanics- Adverb

Adverb:
- A word that describes, limits, or qualifies a verb, adjective, or other adverb-- tells when, where, why, or how something was done.

211

Writing Mechanics- Pronoun

Pronoun:
- Word that replaces a noun to avoid repeating the noun, e.g., I, you, he, she, it, we, they.

212

Writing Mechanics- Conjunction

Conjunction:
- Joins two words, phrase, or clauses together, e.g., for, and, not, but, or, yet, so.

213

Writing Mechanics- Preposition

Preposition:
- Joins a noun to some other part of the sentence-- often describes the position, direction, location, time, or place of a noun.

214

Writing Mechanics- Independent clause



Independent clause:
- The basic unit of a sentence. The subject and verb must form a complete thought, e.g., the medical assistant collected some blood.

215

Writing Mechanics- Article

Article:
- A word that introduces a noun, e.g., a, an, the.

216

Writing Mechanics- Phrase

Phrase:
- A group of words that does not contain a subject (includes a noun) or a verb that complement each other, e.g., the medical assistant.

217

Writing Mechanics- Clause

Clause:
- A group of words that contains both a subject and a verb that complements each other, e.g., the medical assistant collected.

218

Writing Mechanics- Independent clause

Independent clause:
- The basic unit of a sentence. The subject and verb must form a complete thought, e.g., the medical assistant collected some blood.

219

Writing Mechanics- Dependent clause

Dependent clause:
- Contains a subject and verb, but the clause cannot be identified by the use of dependent clause markers, e.g., because, since, when, while, until, if, as, though, although, unless, after, before, once, whether.

220

Writing Mechanics- Essential clause or phrase

Essential clause or phrase:
- Modifies a noun and is critical to the meaning of the sentence.

221

Writing Mechanics- Nonessential clause or phrase

Nonessential or phrase:
- Adds extra information to a sentence. This information can be eliminated from the sentence without jeopardizing the meaning of the sentence.

222

Writing Mechanics- Sentence

Sentence:
- Has at least an independent clause-- a subject and verb that expresses a complete thought.

223

Writing Mechanics- Simple sentences

Simple sentences:
- Includes one independent clause-- a sentence that can stand alone, e.g., The medical assistant called in late.

224

Writing Mechanics- Apostrophe ( ' )



Apostrophe"
- Indicates the possessive of nouns, e.g., the girl's mother, Degas's art, birds' migration.
- Marks the omission of letters in contracted words, e.g., didn't, they're, he'd.

225

Writing Mechanics- Compound sentence

Compound sentence:
- On that contains two independent clauses joined by a coordinating conjunction, e.g., The medical assistant called in late because she was delayed by traffic.

226

Writing Mechanics- Complex sentence

Complex sentence:
- Includes an independent clause and one or more dependent clauses-- cannot stand alone as a sentence, but modifies or enhances the independent clause, e.g., the medical assistant, who is not an early riser, called in late.

227

Writing Mechanics- Compound complex sentence

Compound complex sentence:
- Includes tow or more independent clauses and one or more dependent clauses, e.g., The medical assistant, who is not an early riser, called in late because she was delayed by traffic.

228

Writing Mechanics- Dash -










Dash:
- Marks and abrupt change in the sentence structure, e.g.,Dr. Adams just arrived to the OR-- what do you make of his choice of the tie.
- Replaces commas or parentheses to emphasize a parenthetical phrase, e.g., She had the facts right--the glucose was high and the WBC count was low--however, she dr3w the wrong collection.
- Introduces defining phrases, e.g., A type I error--alpha.

229

Writing Mechanics- Ellipsis (...)





Ellipsis:
- Indicates the omission of one or more words within a quotation, e.g., "Four score and seven..."
- Indicates faltering speech or an unfinished sentence, e.g., no, no, please don't..ugh.

230

Writing Mechanics- Brackets [ ]

Brackets:
- Encloses editorial comments within quoted material, e.g., He piqued [sic] outside the window.
- Encloses insertions that supply missing letters, e.g., She decide[d] otherwise.
- To serve as parentheses within parentheses, e.g., the Greek letter m (u [mu]).

231

Writing Mechanics- Colon :

Colon ( : )
- Introduces an amplifying words or phrase, e.g., There is only person who can do the job: Patrick.
- Introduces lengthy quoted material set off from the rest of the text by indentation without quotation marks,

232

Writing Mechanics- Comma ,

Comma:
- Separates a series of three or more items, e.g., She passed the forceps, scalpel, and gauze in that order.
- Separates state from city and the remaining sentence, e.g., She went to Vincennes, Indianan, to go to school.

233

Writing Mechanics- Dash -










Dash:
- Marks and abrupt change in the sentence structure, e.g.,Dr. Adams just arrived to the OR-- what do you make of his choice of the tie.
- Replaces commas or parentheses to emphasize a parenthetical phrase, e.g., She had the facts right--the glucose was high and the WBC count was low--however, she dr3w the wrong collection.
- Introduces defining phrases, e.g., A type I error--alpha.

234

Writing Mechanics- Ellipsis (...)





Ellipsis:
- Indicates the omission of one or more words within a quotation, e.g., "Four score and seven..."
- Indicates faltering speech or an unfinished sentence, e.g., no, no, please don't..ugh.

235

Writing Mechanics- Quotation marks double (" ")

Quotation marks double:
- Encloses direct quotation but no indirect quotation, e.g., "The treatment is complete," he said. He said the treatment was complete.

236

Writing Mechanics- Hyphen (-)

Hyphen:
- Links elements in compound words, e.g., post-recovery, middle-of-the-road.

237

Writing Mechanics- Parenthesis

Encloses phrases that provide illuminating information, e.g., Nurse Jones (an alumnus) gave the commencement address.

238

Writing Mechanics- Period

Period:
- Marks the end of a sentence, e.g., Every day in every way, I am getting better and better.
- Periods are placed inside quotations marks.
- Periods are placed outside the parenthesis if the parenthetical sentence is part of a larger sentence. They are placed inside the parentheses if not part of of another sentence.
- Use it to end a rhetorical question.

239

Writing Mechanics- Question mark

Question mark:
- Ends a direct question, e.g., When will the physician arrive.
- Indicates uncertainly about a fact.

240

Writing Mechanics- Quotation marks double

Quotation marks double:
- Encloses direct quotation but no indirect quotation, e.g., "The treatment is complete," he said. He said the treatment was complete.

241

Writing Mechanics- Quotation marks, single

Encloses quoted material:
- Encloses quoted material within quoted material, e.g., She said, "I distinctly heard the student ask, 'Will this be testable?'"

242

Letters structure- Closing

Closing:
- Complimentary close: Placed two lines below the line of the body.
- Formal: Truly yours and Very truly yours.
- Common: Sincerely and Sincerely yours.
- Mixed punctuation: Comma follow the complimentary close.
- Open punctuation: No terminal punctuation.

243

Writing Mechanics- Grammar in brief

The number of the subject should match that of the verb: If the noun is singular so should the verb; if the noun is plural the verb should is plural.

244

Letters structure- Heading

Heading:
- Usually composed of preprinted letterhead within the upper 2 inches of the page.
- Dateline: Date of correspondence would be placed at least three lines below the letterhead or somewhere between lines 12 and 15.

245

Letters structure- Opening

Opening:
- Inside address: Placed four lines below the dateline.
- Attention line: Optional; placed two lines below the inside address. Directs the letter to a particular person or department when the letter is addressed to an organization.
- Salutation line: Optional; The opening greeting; placed two lines below attention line or inside address as appropriate.
- Subject line: Optional; placed two lines below the salutation. Indicates what the letter is about.

246

Letters structure- Body

Body:
- Contains the message; each line is single-spaced.
- Paragraphs are double-spaced.

247

Letters structure- Closing

Closing:
- Complimentary close: Placed two lines below the line of the body.
- Formal: Truly yours and Very truly yours.
- Common: Sincerely and Sincerely yours.
- Mixed punctuation: Comma follow the complimentary close.
- Open punctuation: No terminal punctuation.

248

Letters structure- Signature line

Signature line:
- Placed four to five lines below the complimentary close.

249

Letters structure- Reference notation

Reference notation:
- Placed two lines below the signature.

250

Letters structure- Enclosure notation

Enclosure notation:
- Placed one or two lines below the reference notation.

251

Letters structure- Copy notation

Copy notation:
- Placed on or two lines below enclosure notation.
- bc: Blind copy. Indicates a copy has been sent to a third party without the recipient's knowledge.

252

Letter styles- Full block

Full block:
- All lines begin flush at the left margin.

253

Letter styles- Modified block

Modified block:
- All lines begin flush at the left margin except the dateline and complimentary close, which begin at the center of the page.

254

Letter styles- Semiblock

Semiblock:
- Same as modified block except the beginning of each paragraph is indented five spaces.

255

Letter styles- Hanging identification

Hanging identification:
- Same as modified block except all lines of each paragraph are indented five spaces except the first line of each paragraph.

256

Letter styles- Simplified

Simplified:
- Same as full block except there is no salutation or complimentary close.

257

Margins

Margins: Free space along the four edges of the page.
- Short letter (less than 100 words): use 2 inch margins.
- Medium letter (100 - 200 words): use 1.5inch margins.
- Long letter (more than 200 words): use 1 inch margins

258

Multiple pages

- Type the recipient's name seven lines from the top edge of the page.
- Type the page number one line below the recipients name.
- Type the date one line below the page number.

Example:
Name
Page number
Date

259

Spacing

- Six lines (7 returns) equal 1 inch.
- Pitch: Number of characters per inch of horizontal document space.
- Pica: 10 character per inch
- Elite: 12 character per inch

260

Envelopes

Common size:
- # 63/4: 61/2 inch x 35/8 inch
- # 10: 91/2 inch x 41/8 inch

261

Return address- Senders address

- Placed three lines from top edge and five spaces from the left edge.
- Use all capital letters without punctuation.

262

Recipient's address

- #6 3/4: Two inches from top edge, and 2.5 inches from left edge.
- #10: Two inches from top edge, and 4 inches from left margin.
- Leave a bottom margin of at least 5/8 inch.

263

Memoranda (memorandum)

- Written communication among workers within an office or organization.
- The message should begin three lines below the last line of the guide words.

264

Reference notation

- Identifies the transcriber's initials.
- Placed two lines below the last line of the message.

265

Copy notation

- Indicates a copy of the memo that was provided to a third party.
- placed two lines below last lines of message or reference notation.

266

Multiple pages

- Type the subject line seven lines from the top edge of the page.
- Type the page number one line below the subject line.
- Type the date one line below the page number.

267

Manuscripts

- A written document that is submitted for publication.
- Different professional organizations, e.g., American Medical Assiciation (AMA) or American Psychological Association (APA), employ different standard formats for manuscript preparation and submission.

268

Manuscripts- Title page

Title page:
- Identifies the title or main theme of the manuscript.
- The title, names of the authors, and their credential are usually centered vertically and horizontally.

269

Billing Statements- Acknowledgments

- Identifies those who have provided assistance on the research or preparation of the manuscript.
- Usually placed at the bottom of the or a separate page following the title page.

270

Manuscripts- Abstract

Abstract:
- Summary of the manuscript in 100 to 200 words.
- Usually placed at the bottom half of the title page, or at the beginning of the text.

271

Manuscripts- text

Text:
- Title is typed in all capital, 13 lines from the top page.
- The body of the text begins three lines below the title.
- The text is usually double spaced.

272

Manuscripts- References

References:
- Identifying your published work of others in the text.
- The references would then be listed numerically at the end of the manuscript.
- References may also be cited using the author's last name, year of publication, and page numbers in parenthesis. The references would then be listed alphabetically by author at the end if the manuscript.

Example:
(Cody, 2010, p.45).

273

Footnotes:
- Cites references or other explanation information near the bottom of the page of which the referenced materialism printed rather than at the end of the manuscript.

Manuscripts- Footnotes

274

Manuscripts- Bibliography

Bibliography: List of source material or references used in preparing a written work.
- Articles: Author, "title," journal, date, publication volume and number, pages.
- Example:
Cody, J.P., "Measuring Your Study Skills," The Professional Medical Assistant, July/August, 1992, 35:4, pp.13-17.
- Texts: Author, title, publisher, year, pages.
- Example:
Cody, J.P., The CMA Review Manual, Delmar Cengage Learning, New York, 2005, p. 22.

275

Manuscripts- Illustrations

Illustrations:
- Placed on separate sheets and assigned consecutive figure numbers.

276

Manuscripts- Tables

Tables:
- Placed on separate sheet and assigned consecutive table numbers.

277

Manuscripts- Reprints

Reprints:
- Copies of a published article in pamphlet form to be given to interested colleagues.

278

Curriculum Vitae (CV)

- Latin for "Study of Life".
- CVs area type of resume for selected professionals such as other healthcare providers and academicians, especially with a doctorate degrees.

279

Curriculum Vitae (CV) heading- Identifying information

Identifying information:
- Name, address, phone number

280

Curriculum Vitae (CV) heading- Family information

Family information:
- Although less common today, may identify name of spouse (including years of marriage) and names and ages of children.

281

Curriculum Vitae (CV) heading- Education

Education:
- Highest degree first. Degree, major, college, year of graduation.

282

Curriculum Vitae (CV) heading- Internship/residences

Internship/residences:
- For physicians and other health professional-- specialty, sponsoring organization, and dates.

283

Curriculum Vitae (CV) heading- Licenses and certifications

Licenses and certifications:
- Name of license, number, and expiration date.

284

Curriculum Vitae (CV) heading- Experience

Experience:
- Professional positions held in reverse chronological order.

285

Curriculum Vitae (CV) heading- Memberships

Memberships:
- Include professional membership level, and service posts, e.g., president, treasurer, secretary, etc.

286

Curriculum Vitae (CV) heading- community service

Community service:
- Work performed with community and nonprofit organization, as well as service on boards and advisory committee.

287

Curriculum Vitae (CV) heading- Research activity

Research activity:
- Briefly describe past and current research work.

288

Curriculum Vitae (CV) heading- Publications

Publications:
- Published articles and books, as weeks as unpublished manuscripts.

289

Curriculum Vitae (CV) heading- Presentations

Presentations:
- Speeches or papers given to seminars or conferences; other speaking engagements, panel discussion, and the like. Note title, place and date.

290

Curriculum Vitae (CV) heading- Awards and honors

Awards and honors:
- Identify instances and tokens of special recognition.

291

Curriculum Vitae (CV) heading- Personal interests and hobbies

Personal interests and hobbies:
- Although less common today, this may be included as well.

292

Medical transcription

- Organizations that engages in medical transcription adhere to publish transcription formats and styles, or develop and document their own.
- Regardless of the format and style adopted, appearance, clarity, and legibility are the man consideration.

293

Medical transcription- Document title

Document title:
- Centered in all capital letters in the first line. Underscoring optional.

294

Medical transcription- Identifying information

Identifying information:
- Patient's name, record number, providers name, date of admission, and other similar information is typed at the left margin as header titles in capital and boldface lowercase letters, followed by a colon.
- Each header title is double-spaced.
- Identifying information is 2 spaces after the colon.

295

Medical transcription- Major headings

Major headings:
- Typed in all capital letters followed by a colon whether indicated or not. Underscoring, boldfacing, or typing on a separate line is optional.

296

Medical transcription- Secondary subheadings

Secondary subheadings:
- Typed in all capital letters followed by a colon and two spaces and inserted as dictated. Placement on a separate line is optional.

297

Medical transcription- Tertiary subheadings

Tertiary subheadings:
- Typed in capital and lowercase followed by a colon and two spaces. They are typed only if dictated within the narrative following the secondary subheading.