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abbrevs and questions

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 Reviewing and reorganizing the file to remove outdated or irrelevant information and putting it into another location.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.