Chapter 41MAA Medical Record Management

Acronym
A word formed from the first letters in a name
Active record
The medical record of a patient who has been seen within a time frame specified by the office (usually 2-3 years)
Cross-index
To file under one unit and use a guide or card filed under another unit that refers to the primary filing location
Electronic health record (EMR)
An individual patients health record in digital format. Also called an Electronic medical record
Filing system
The way in which records are arranged. Common filing systems in the medical office include: alpahbetic, numeric, by subject, or chronologic
Health information exchange (HIE)
The electronic exchange of health care-related data among different institutions
Inactive record
The medical record of a patient who has not been seen within the last 2-3 years, or some other time frame specified by a given medical office
Medical record management
Activities related to the creation, management, use, and disposition of patient medical records
Nationwide Health Information Network (NHIN)
A set of standards, services, and policies to facilitate national HIE (health information exchange)
Outguide
A cardboard or plastic card to insert in a file when a medical record is removed
Sorter
A device that facilitates putting papers or records in alphabetic or numeric order
Surname
Last name or family name of an individual; used as the first indexing unit in alphabetic filing
Tab
A projection of a folder that extends beyond the top or side of the folder
Terminal digit filing
A chronologic filing system that uses the last number or number group as the first indexing unit
Indexing units
Pieces of information used to identify a correct filing location
Paper-based medical records
Many medical records still rely on this to document care
What are 2 things EMR’s offer as an advantage
Medical information is always legible and Information is easy to retrieve
Name 2 types of storage equipment
File cabinets and shelf filing units
Name 3 things you need for filing supplies
File folders, folder labels, and chart dividers
What are the 2 types of filing systems
Alpahbetic and numeric
Name the 8 rules for Alphabetic filing
Individual names, Prefixes, Abbreviations and nicknames, Hyphenation, Titles and Seniority terms, Names of Married women, Companies and Businesses, and Identical names
Name the 2 types of Numeric filing
Terminal digit filing and Consecutive filing
Consecutive Filing Systems
numbers are arranged and filed from the lowest to the highest.
Tickler file
used to ‘tickle’ the memory by serving as a reminder that a specific action must be taken on a specific date, is a type of chronologic system
Statute of limitations
Each state has a law limiting the time period for beginning a lawsuit for malpractice