Save
Busy. Please wait.
Log in with Clever
or
show password
Forgot Password?
Don't have an account?  Sign up 
Sign up using Clever
or
Username is available taken
show password


Make sure to remember your password. If you forget it there is no way for StudyStack to send you a reset link. You would need to create a new account. Your email address is only used to allow you to reset your password. See our Privacy Policy and Terms of Service.

Already a StudyStack user? Log In

Reset Password
Enter the associated with your account, and we'll email you a link to reset your password.
focusNode
Didn't know it?
click below
 
Knew it?
click below
Don't Know
Remaining cards (0)
Know
0:00
edit
Embed Code - If you would like this activity on your web page, copy the script below and paste it into your web page.

  Normal Size     Small Size show me how

HIM--purpleMod

abbrevs and questions

QuestionAnswer
adl Activities of Daily Living
bp Blood Pressure
CC Chief Complaint
CNS Central Nervous System
CPE/PE Complete Physical Examination
DOB Date Of Birth
Dx, Diag Diagnosis
F.Hx Family History
NAD No Appreciable Disease
NYD Not Yet Diagnosed
EMR Electronic Medical Records
CPP Cummulative Patient Profile
S/S Signs & Symptoms
POMR Patient Oriented Medical Records
SOAP Subjective Objective Assessment Plan
wt. Weight
Tx Treatment
TPR Temperature, Pulse, Respirations
SHx Social History
Rx Prescription, treatment
R/O Rule Out
pt. Patient
Prog. Prognosis
PI Present Illness
What is meant by the term "Health Record"? Any documentation relating to a healthcare client. It could be a single document or a collection of documents. Paper or Computerized
List 5 uses of a health record Medical Legal Purposes, Teaching, Funding initiative, Quality Monitoring, Research
What is a Chart? It is a folder containing all the records relating to a clients care with a facility. Papre or Computerized.
List the common parts ofa chart. Clients name, address, birth date & health card number. Must be kept neat, accurate & complete. Each encounter & service entered. Stored safely & properly. Kept confidential, relevent history obtained, results, advice given.
WhMpst charts contain same types of records, they are? History, CPP, list of allergies, physical assessment, lab sheets or reports, consultation reports/letters, growth chart.
Define the term "archiving" a chart. When would thi sbe necessary? Removing a file from active status & storing it in a secondary location. When a patient leaves for any reason or dies. Must be maintained for 10yrs after the date of last contact.
Explain the process of "purging" a chart. Reviewing and reorganizing the file to remove outdated or irrelevant information and putting it into another location.
List and explain 3 different methods of filing. Alphabetic:last name first, followed by first name. *Oldest and the easiest. Numeric: Sequential order or terminal digit. Colour coding: Each letter or number may have a specific colour.
Explain the difference between Centralized and Decentralized filing? Centralized is designated to one Centralized location, which houses all records ex. Hospital Health Information Services. Decentralized is allowing parts of the patient record to reside in other areas, ex. in a hospital.
What is an auxiliary files? When would you use this? A temporary filing space for files in current use. ex. if you are holding the file for the physician to look at for reviewing, purging, waiting for a report to add to the file.
If records are computerized what criteria must be met according to the OMA? System must provide a means of access to the record of each client, by name & possibly health card number. Must be able to print recorded information promptly. Must include security password. System must automatically back up files & allow for recovery.
If records are computerized what criteria must be met according to the OMA? continued.. system must provide visual display of recorded information. Must have an audit trail.
Outline the life cycle of a record, describe first 2 stages. Creation: the initial retrieval of info. Maintanence: Includes organization,so that contents are accessible.
Outline the life cycle of a record, describe last 2 stages. Provision: Policies will dictate who may have access to patient record, for what purposes & for how long. Disposition: Is considered active if the client is active & may seek treatment.Chart cannot be destroyed for 10yrs but may be purged.
Created by: Brittanyyy
Popular Medical sets

 

 



Voices

Use these flashcards to help memorize information. Look at the large card and try to recall what is on the other side. Then click the card to flip it. If you knew the answer, click the green Know box. Otherwise, click the red Don't know box.

When you've placed seven or more cards in the Don't know box, click "retry" to try those cards again.

If you've accidentally put the card in the wrong box, just click on the card to take it out of the box.

You can also use your keyboard to move the cards as follows:

If you are logged in to your account, this website will remember which cards you know and don't know so that they are in the same box the next time you log in.

When you need a break, try one of the other activities listed below the flashcards like Matching, Snowman, or Hungry Bug. Although it may feel like you're playing a game, your brain is still making more connections with the information to help you out.

To see how well you know the information, try the Quiz or Test activity.

Pass complete!
"Know" box contains:
Time elapsed:
Retries:
restart all cards