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SBGR
SBGR ALH 151 Week 2 Ch 13 Pearson's (2012 EK)
Question | Answer |
---|---|
active records | medical files of patients who are currently being seen by the physician that may cover 1 - 5 years, depending on office policy |
addendum | addition to the original document |
alphabetic filing | filing system based on the letters of the alphabet |
chronological medical record | patient record that follows the patient over a period of time, with each visit consisting of a new entry by date, rather than by symptoms or diagnosis |
closed records | medical files of patients who have indicated that they are no longer a patient, or patients that have died, that are kept in storage for legal reasons |
electronic medical record (EMR) | electronic means of gathering, documenting, and storing information about the patient and the care received in the medical setting; also known as the electronic medical record |
inactive records | medical files for patients who have not been seen within the time period established by office policy (generally 1-5 years) |
medical record | source of all documentation relating to the patient; also known as patient files or patient charts or patient's record |
microfiche | sheets of microfilm |
microfilm | miniaturized photos of records |
numeric filing | filing system that assigns an identification number to each person's name |
problem-oriented medical record (POMR) | patient record organized according to diagnoses |
source-oriented medical record (SOMR) | patient file organized according to the source of information |
subjective, objective, assessment, and plan (SOAP) | patient chart notes organized according to symptoms, signs, assessment, and plan of treatment |
terminal-digit filing | filing system based on the last digits of the ID number that evenly distributes the files within the entire filing system |