Questions and Answers
What are Active Records?
What does Addendum mean?
Things to be added
Which filing system is based on the letters of the alphabet?
What are Chronological Medical Records?
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What are Closed Records?
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What does EMR stand for?
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What are Inactive Records?
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What is Microfiche?
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What is Numeric Filing?
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What does SOMR stand for?
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What does POMR stand for?
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What does SOAP stand for?
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What is Terminal Digit Filing?
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What is a Medical Record?
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What is Microfilm?
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Study Notes
Active Records
- Refers to medical files for patients currently under care by a physician.
- Typically covers a duration of one to five years, varying by office policy.
Addendum
- Denotes additional items or information that need to be included.
Alphabetic Filing
- A filing system that organizes documents based on the order of letters in the alphabet.
Chronological Medical Records
- Patient records that chronicle visits over time, recorded sequentially by date rather than by symptoms or diagnosis.
Closed Records
- Medical files for patients who have either ceased treatment or deceased.
- Retained in storage primarily for legal purposes.
EMR (Electronic Medical Record)
- An electronic method for collecting, documenting, and storing patient information and medical care history.
- Also referred to as electronic health record (EHR).
Inactive Records
- Files pertaining to patients who have not had any visits within an office-defined timeframe, generally one to five years.
Microfiche
- Composed of sheets that encapsulate microfilm images for storage and documentation.
Numeric Filing
- A system assigning unique identification numbers to individuals' names for organization.
SOMR (Source-Oriented Medical Record)
- A patient file organized based on the sources of information, emphasizing the origin rather than the condition.
POMR (Problem-Oriented Medical Record)
- A medical record organized with a focus on the patient's diagnoses.
SOAP (Subjective, Objective, Assessment, Plan)
- A structured format for patient charting that encompasses subjective symptoms, objective signs, assessment, and plan of action.
Terminal Digit Filing
- Filing system that organizes records based on the last digits of identification numbers.
- Promotes an even distribution of files across the filing system.
Medical Record
- The comprehensive source of all documentation related to a patient, also known as patient files, patient charts, or patient records.
Microfilm
- Utilizes miniaturized images of records, offering a compact storage option for large volumes of documentation.
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Description
Test your knowledge with flashcards covering key terms from Chapter 13 on medical records. This quiz includes definitions for concepts such as Active Records, Addendum, Alphabetic filing, and Chronological medical records. Perfect for students or professionals in healthcare administration.
