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What replaces a file folder when it is removed from the file cabinet?
Out guides
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What is a chart format that is arranged according to a pt's health complaint?
Problem-oriented medical record (POMR)
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What is a type of chart format that divides each patient problem into subjective data, objective data, assessment, and plan for treatment?
SOAP
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What is the method of filing that organizes recoreds by their final digits?
Terminal-digit filing
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What is a reminder aid that organizes events by date and should be checked frequently and organized for use?
Tickler file
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Who owns the information in a medical chart?
The patient
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What provides evidence of patient assessments, interventions, and communications?
Medical records
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Continuity of care, filing insurance claims, and resolving legal matters are examples of using what kind of record?
Patient record
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Planning & Care: This is a legal form that protects all health care personnel when caring for the patient by signifying that the pt has been informed of treatment risks and alternatives
Consent to treat form
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Who owns the pts medical records
The physician
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An organized medical record that has dividers to separate the medical information and is grouped by the type of service provided is in what format?
Source-oriented record format
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Information provided by the pt as a CC is what type of data? (feels like nails into my head)
Subjective
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Information obtained through the physical examination; observed or seen is what kind of data?
Objective
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The impression the Dr. has about a pts symptoms: aka a preliminary diagnosis is a what?
Assessment
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The plan of action or treatment including diagnostic testing and medications?
Plan
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National mandate states never to use what while correcting in a pts chart, and what do they advise?
Never use white out, instead draw a line through the error and write correction and initial.
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What is the most common method of filing and is broken into units?
Alphabetical
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When alphabetizing the last name is the what (first unit)?
Key unit
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What is the 2nd unit when filing alphabetically?
First name or initial
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How would "St." be indexed when filing alphabetically?
As if it were spelled out "Saint"
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What type of system can be used with alphabetical or numerical filing and should be known by everyone in the office?
Color coding
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