Delmar Chapters 14 & 15 Study Guide
Quiz yourself by thinking what should be in
each of the black spaces below before clicking
on it to display the answer.
Help!
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| Legal Importance of Accurate Medical Records: | Serve as a written record that proves patient care.
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| Legal Standards | If there is no record of any piece of informatio related to a patient and that patient's care and treatment, then it did not happen.
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| Out Guide | Use: Tracking patient's charts. Info: Also known at a "Checkout System", which include date and who removed it.
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| Indexing | Titles: separates units at the end.
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| Indexing (cont'd) | Rule When titles are used, they are considered as separate indexing units, If the title appears with first and last names, the title is considered to be the last indexing unit. Patient charts,the first name always accompanies, title and last name.
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| Indexing (II, III, vs, Jr., Sr) &$# index separetly as words *Numbers are first | Seniority and professional or academic degrees are the last indexing unit and are used only to distinguish identical names. Numeric units are broken down such that numeric seniority terms are filed before alphabetic terms. &$#-index separately as words.
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| Tickler File | A method that serves as a reminder that some action needs to be taken at a date in the future.
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| Purge System | Record Purging: Sorting through records and removing those not in active use.
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| Data Base | Patient demographics, insurance carrier, listings, accounting records and mailing list.
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| Put In Order | (1) John Doe (2) John B. Doe (3) John B. Doe III(4) Dr. John B. Doe (5) John B. Doe Jr.
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| Procedural Steps for Filing | (1) Inspect the report to identify the patient, subject, or file to whom information belongs. (2) Index-use the indexing process to determine how the chart would be located, properly identifying indexing units and their order.
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| Procedural Steps for Filing (cont'd) | (3)Coding in medical records is the process of marking data indicate how information is to be filed. (4)Sort: Reports/documents to be filed, sort then into units according to the captions on the charts.
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| Procedural Steps for Filing (cont'd) | (5) File: The papers are placed in the proper charts and the charts returned to their proper place in the medical recods section.
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| Business Writing (Corresponds to the salutation) | Language-use language reader can understand. Punctuation: What follows a salutation, a colon.
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| Mail Processing | The management of written communications also involves developing procedure for sorting, distributing, and otherwise processing incoming mail. It also includes posting and shipping outgoing items by the most cost and time-effective manner.
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| Reports Operative-written post operative Consultation-dictated by a consultating physician | History and Physical: documents information relating to the patient's main reason for treatment.
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