Medical Records Management ch. 14

alphabetic filing
any system that arranges names or topics according to the sequence of the letters in the alphabet.
alphanumeric
of or relating to systems made up combinations of letters and numbers.
audit
a formal examination of an organization’s or individual’s accounts or financial situation; a methodic examination and review.
augment
to make greater, more numerous, larger, or more intense.
caption
a heading, title, or subtitle under which records are filed.
chronologic order
of, relating to, or arranged in or according to the order of time.
continuity of care
continuation of care smoothly from one provider to another, so that the patient recieves the most benefit and no interruption of care.
dictation
the act or manner of uttering words to be transcribed.
direct filing system
a filing system in which materials can be located without consulting an intermediary source of reference.
gleaned
gathered bit by bit; picked over in search of relevant material.
indirect filing system
a filing system in which an intermediary source of reference, such as a card file, must be consulted to locate specific files.
microfilm
a film bearing a photographic record on a reduced scale of printed or other graphic matter.
numeric filing
the filing of records, correspondence, or cards by number.
objective information
information that is gathered by watching or observation of a patient.
obliteration
act of making undecipherable or imperceptible by obscuring or wearing away.
OUTfolder
a folder used to provide space for the temporary filing of materials.
OUTguide
a heavy guide that is used to replace a folder that has been temporarily moved from the filing space.
power of attorney
a legal instrument authorizing one to act as the attorney or agent of the grantor.
pressboard
a strong, highly glazed composition board resembling vulcanized fiber; heavy card stock.
procrastination
the international postponement of doing something that should be done.
provisional diagnosis
a temporary diagnosis made before all test results have been received.
quality control
an aggregate of activities designed to ensure adequate quality, especially in manufactured products or in the service industries.
requisites
entities considered essential or necessary.
retention schedule
a method or plan for retaining or keeping medical records, and their movement from active, to inactive, to closed filing.
shelf filing
a system that uses open shelves rather than cabinets for storing records.
shingling
a method of filing whereby one report is laid on top of the older report, resembling the shingles of a roof.
subjective information
information that is gained by questioning that patient or taken from a form.
tickler file
a chronologic file used as a reminder that something must be taken care of on a certain date.
transcription
to make a written copy of, either in longhand or by machine.
vested
granted or endowed with a particular authority, right, or property; to have a special intrest in.
Indexing Rules
-Last names are considered first in filing; When a letter is different in two names, the letter determines the order of filing.
ex. Morgan & Molly ( Molly would come before Morgan)

-Initials precede a name beginning with the same letter. This illustrates the librarian’s rule “Nothing comes before something.”
ex. Smith, J. & Smith, Jason (Smith J. would come first.)

-Hyphenated names: The hyphentated elements of a name, whether first name, middle name or sur-name, are considered to be one unit.
ex. Carlotta Freeman-Duque if filed as Freemanduque, Carlotta.

-The apostrophe is disregarded in filing.
ex. Anderson’s Surgical Supply would be Andersons Surgical Supply.

-When indexing a foreign name & you are unable to distinguish the first and last name, index each part of the name in the order in which it is written, If you cannot make the distinction, you should use the last name as the first indexing unit.

-Names with prefixes are filed in the ususal alphabetic order, with the prefix being considered as a part of the name.
ex. von Schmidt if filed as Vonschmidt.

-Abbreviated parts of a name are indexed as written if that is the form generally used by that person.
ex. Ste. Marie is filed as Stemarie

-Mac and Mc are filed in their regular place in the alphabet.
ex. MacDonald
MacHale
McWilliams

-The name of a married woman is indexed by her legal name (her husbands surname, her given name, and her middle name or maiden surname.)
ex. Mary Doe Jones would be indexed as, Doe, Mary Jones ( Mrs. John L.) not Doe, Mrs. John L. (unless first name is unknown.)

-Titles, when followed by a complete name, may be used as the last filing unit if needed to distinguish from another identical name. Titles without complete names are considered the first indexing unit.
ex. Madame Sylvia

-Terms of seniority, or professional or academis degree, are used only to distinguish from an identical name.
ex. two patients have the name Theodore, Wilson. You can index one patient as Theodore Wilson, PhD.

-Articles such as The and A are disregarded in indexing.