Medical Record Management

Flashcards covering medical record systems, components of patient records, filing methods, and legal considerations based on the Medical Record Management lecture.

Electronic Medical Records (EMR)

An electronic version of a patient’s medical record that is used by a single healthcare facility; may include medical history, diagnoses, treatment plans, and laboratory results.

Centers for Medicare & Medicaid Services (CMS)

A federal agency within the US Department of Health and Human Services that is responsible for Medicare and Medicaid.

Meaningful use

Standards established by CMS to create incentives for the use of electronic health records (EHR).

Demographic information

A component of a patient’s medical record containing name, DOB, and contact information.

Administrative records

Records such as health insurance, billing, appointments, referrals, information requests, and letters.

Social history

A portion of the medical record that includes education, living conditions, health habits, and alcohol/tobacco use.

Electronic Health Records (EHR)

Digital patient records that can be accessed by multiple users across many healthcare systems and include billing and scheduling functions.

HITECH

Legislation that mandated increased security requirements for Electronic Health Record systems.

Straight numerical filing

A paper chart filing system where files are organized from the lowest to the highest assigned number.

Terminal digit filing

A system of filing paper records according to the final digit of the assigned number.

Source-oriented medical record (SOMR)

A method of organizing paper medical records according to source or category.

Problem-oriented medical record

A method of organizing paper medical records according to the patient’s problems and diagnoses.

Personal health record (PHR)

An electronic collection of a patient’s health history and medical information.

Computerized provider order entry (CPOE)

A method of entering orders for healthcare services, such as laboratory or diagnostic tests, within a patient’s EHR.

Requisition

An order for diagnostic tests to be completed.

Superbill

A document listing diagnosis and treatment codes, charges for treatment provided, and any payment made by the patient.

Patient Portals

Electronic access points that directly involve the patient in their healthcare and provide common medical office functions.

HIPAA

Federal requirements that MAs must follow for backing up electronic medical information and protecting patient privacy.