logo image

Chapter 14, medical records management

Accession record (numeric system)
Log book used to assign numbers to correspondence or patients
Method of designation used on file guides
Notation on a file to direct the reader to a specific record that may be filed under more than one name/subject (e.g. married name/maiden name or foreign names) where the surname is not easily recognizable.
Selecting the name, subject, or number under which to file a record and determining the order in which the units should be considered.
Key unit
First indexing unit of the file segment
Out guide or sheet
Card, folder, or slip of paper inserted temporarily in the files to replace a record that has been retrieved from the files
Problem-oriented medical record (POMR)
The type of patient chart recordkeeping that uses a sheep at a prominent location in the chart to list vital identification data. Patient medical problems are identified by a number that corresponds to the charting; for example, bronchitis is #1, a broken wrist is #2, and so forth.
Method of maintaining order in the files by separating active from inactive and closed file.
Acronym for patient progress notes based on subjective impressions (S), objective clinical evidence (O), assessment or diagnosis (A), plans for further studies (P), education for the pt. (E), and response of pt. to education and care given (R).
Source-oriented medical record (SOMR)
A type of patient chart record keeping that includes separate sections for different sources of patient information, such as laboratory reports, pathology reports, and progress notes.
Tickler file
System to remind of action to be taken on a certain date
Each part of a name (business or person), words, or numbers that will be indexed and coded for filing.

Need essay sample on "Chapter 14, medical records management"? We will write a custom essay sample specifically for you for only $ 13.90/page

Can’t wait to take that assignment burden offyour shoulders?

Let us know what it is and we will show you how it can be done!
Sorry, but copying text is forbidden on this website. If you need this or any other sample, please register

Already on Businessays? Login here

No, thanks. I prefer suffering on my own
Sorry, but copying text is forbidden on this website. If you need this or any other sample register now and get a free access to all papers, carefully proofread and edited by our experts.
Sign in / Sign up
No, thanks. I prefer suffering on my own
Not quite the topic you need?
We would be happy to write it
Join and witness the magic
Service Open At All Times
Complete Buyer Protection
Plagiarism-Free Writing

Emily from Businessays

Hi there, would you like to get such a paper? How about receiving a customized one? Check it out https://goo.gl/chNgQy

We use cookies to give you the best experience possible. By continuing we’ll assume you’re on board with our cookie policy