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Spoken or written words
Communication
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spoken rather than written
Verbal
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_______ communication conveys a strong, powerful message that may be positive or negative.
Non-verbal
- facial expressions: smiling
- body language: cross arms
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Placing your own feelings onto another person
projection
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Adopting the feelings of someone else
Introjection
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Medical files of patients who are currently being seen by physician.
Active
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Medical files for patients who have not been seen, according to the time period set up by the office policy
Unactive
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records that are not longer needed, such as when a patient dies, but must keep the file for legal reasons
Archives
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Medical files of patients who have indicated that they are no longer patients or who have died.
Closed
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Diagnosis
Identifying a disease through signs and symptoms
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Filing system which assigns an identification number to each person's name
Numeric filing
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Filing system based on the letters of the alphabet
Alphabetical filing
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stystem assigns a number to patients the first time they are seen or admitted to a hospital
unit filing
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When files are filed sequentially
Straight numbering filing
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Filed middle digit first
Middle digit filing
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A word of oppostie meaning
Antonyms
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A word formed from the initial letter or letters of each of the successive parts or major parts of a compound term
acronyms
Example CPR, VRT, HIV
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one or two or more words or expressions of the same language that have the same or nearly the same meaning in some or all senses
Synonyms
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one of two or more words spelled and pronouced alike but differ in meaning
Homonyms
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one for whom or which something is or is believed to be named
Eponyms
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of or relating to spoken language or speech sounds
Phonetics
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VRT
- voice recognition technology
- Physician speaks into a microphone and it types up what he/she says
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who owes the medical records?
The physician
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Pts responsibility
- authorize any release of information
- request copies
- pay fees
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The medical Transcriptionist should not edit documents when?
when unsure of the meaning or the intent of the statement
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what is a autospy also called?
pathology report
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What should you do when you pull a file?
put in divider breaker
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POMR
problem oriented medical record
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SOAP
Subjective, objective, assessment, plan
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Filing system that assigns patient a different number with each hospital visit
Serial number filing
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adopting the feelings of someone else
introjection
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What report would a MRI be under?
radiology
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Easiest filing method
straight digit filing
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What are alphabetical files broken into?
units
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What are characterists of the alpha z filing system?
yellow with white stripe
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Always answer the phone by the ____ ring
2nd
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How many numbers does the numberic filing system have?
6
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You, us, them are types of what kind of speech?
pronoun
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Closing statements
Yours truly, sincerely
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What is considered registered mail?
money, jewelry
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When the subject in a sentence performs the action, it can be described as_________
active voice
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function to press to answer another call
hold
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how often should you do check back on phone when you have a patient on hold?
30 seconds
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