chapter 14 medical record management

accession record
logbook used to assign numbers to correspondence or patients
caption
method of designation used on file guides
cross reference
notation in a file to direct the reader to a specific record that may be filed under more than one name/ subject 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 filing segment
out guide
card folder or slip of paper inserted temporarily in the file to replace a record that has been retrieved from the files
problem oriented medical record
(POMR)
a type of patient chart recordkeeping that uses a sheet 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
purging
method of maintaining order in the files by separating active from inactive from inactive and closed files
SOAP SOAPER
acronym for patient progress notes based on subjective impressions S objective clinical evidence O assessment or diagnosis A and plans for further studies P
source oriented medical record (SOMR)
a type of patient chart record keeping that includes separate sections for different sources of patient information such as lab reports
tickler file
system to remind of action to be taken on a certain date
unit
each part of a name words or numbers that will be indexed and coded for filing