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Chapter 14, medical records management

Accession record (numeric system)
Log book used to assign numbers to correspondence or patients
Caption
Method of designation used on file guides
Cross-reference
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.
Indexing
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.
Purging
Method of maintaining order in the files by separating active from inactive and closed file.
SOAP/SOAPER
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
Unit
Each part of a name (business or person), words, or numbers that will be indexed and coded for filing.

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