Mod 5The Medical Record, Documentation, and Filing

Vocabulary terms and definitions related to medical records, documentation, and filing.

HIPAA

Health Insurance Portability and Accountability Act; ensures confidentiality of patient’s medical record.

POMR

Problem-Oriented Medical Record; a method of organizing patient records based on their problems.

SOMR

Source-Oriented Medical Record; a method of organizing patient records by the source of information.

Demographic Information

Information that includes a patient’s gender, ethnicity, religion, and marital status.

Continuity of Care

The process of maintaining consistent patient care over time.

EMR

Electronic Medical Record; a digital version of a patient's paper chart.

Legal Protection

The use of medical records to provide legal protection for healthcare providers.

Subjective Information

Information provided by the patient about their personal feelings or experiences.

Objective Information

Information provided by healthcare professionals, such as vital signs and diagnostic tests.

Chain of Custody

A procedure that ensures the integrity and security of specimen testing for legal or quality assurance purposes.

Past Medical History

A record of a patient's previous health issues, surgeries, and treatments.

Patient Bill of Rights

A list of guarantees for those receiving medical care.