Week Three

Question 0

Caption

Answer 0

Method of designation used on file guides

Question 1

Accession Record (numeric system)

Answer 1

Log book used to assign numbers to correspondence or patients

Question 2

Cross Reference

Answer 2

Notation in a file to direct the reader to a specific record that may be filed under more than one name or subject

Question 3

Indexing

Answer 3

Selecting the name, subject, or number under which to file a record and determining the order in which the units should be considered

Question 4

Key Unit

Answer 4

First indexing unit of the filing segment

Question 5

Out Guide or Sheet

Answer 5

Card, folder, or slip of paper inserted temporarily in the files to replace a record that has been retrieved from the files

Question 6

Problem-Oriented Medical Record (POMR)

Answer 6

A type of patient chart record keeping that uses a sheet at a prominent location in the chart to list vital identification data.

Question 7

Purging

Answer 7

Method of maintaining order in the files by separating active from inactive and closed files

Question 8

Soap/Soaper

Answer 8

Acronym for patient progress note based on Subjective impressions(S), Objective clinical evidence(O), Assessment or diagnosis(A), and Plans for further studies(P)

Question 9

Source-Oriented Medical Record (SOMR)

Answer 9

The type of patient chart record keeping that includes separate sections for different sources of patient in formation.
Such as laboratory reports, pathology reports, and progress notes.

Question 10

Tickler File

Answer 10

System to remind of action to be taken on a certain date

Question 11

Unit

Answer 11

Each part of a name (business or person), words, or numbers that will be indexed and coded for filing

Question 12

Chart Notes (Progress notes)

Answer 12

Providers formal or informal notes about presenting problem, physical findings, and plan for treatment for a patient examined in the office, clinic, acute care center, or emergency department

Question 13

Chief Complaints (CC)

Answer 13

Specific symptom or problem for which the patient is seeing the provider today

Question 14

Discharge Summary (DS)

Answer 14

Medical reports that document the hospitalization history of a patient

Question 15

Gross examination

Answer 15

Viewing specimens with the naked eye

Question 16

Health Insurance Portability and Accountability Act (HIPAA)

Answer 16

Government rules, regulations, and procedures resulting from legislation designed to protect the confidentiality of patient information

Question 17

History of Present Illness (HPI)

Answer 17

The chronologic description of the development of the patients illness

Question 18

Out Sourcing

Answer 18

The practice of contracting with a service outside of the clinic or hospital to a company where the task can be accomplished at a lower cost and with a faster turnaround time

Question 19

Operative Report (OR)

Answer 19

Medical reports generated to describe the gross and microscopic examinations performed during a surgical procedure

Question 20

Pathology Report

Answer 20

Medical reports generated to describe the gross and microscopic examinations performed during a surgical procedure

Question 21

Quality Assurance (QA)

Answer 21

Process that provides accurate, complete, consistent health care documentation in a timely manner while making every reasonable effort to resolve inconsistencies, inaccuracies, risk management issues, and other problems

Question 22

Review of Systems (ROS)

Answer 22

Inquires about the system directly related to the problems identified in the history of the present illness