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SBGR

SBGR ALH 151 Week 2 Ch 13 Pearson's (2012 EK)

QuestionAnswer
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
Created by: SBGrandRapids
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