The Medical Record and Medical Records Management

Comprehensive vocabulary flashcards covering the components, legal requirements, and management of medical records based on the lecture transcript.

Medical record

A written record of important information regarding a patient, used to make decisions regarding care, document results, and serve as a legal document.

Patient

An individual receiving medical care.

HIPAA

Health Insurance Portability and Accountability Act of 1996.

HIPAA Privacy Rule

A federal law that protects patient's privacy which went into effect April 14, 2003.

PHI

Protected health information; health information over which patients have more control regarding use and disclosure under HIPAA.

Health care clearinghouses

Entities such as billing services that must comply with the HIPAA Privacy Rule.

Patient Registration Record

A document consisting of demographic and billing information that must be completed by all new patients.

Home health care

The provision of medical and nonmedical care in a patient's home, which must be ordered by a physician.

Diagnostic procedure report

A description and interpretation of a diagnostic procedure.

Diagnostic procedure

An action performed to assist in the diagnosis, management, or treatment of a patient's condition.

Therapeutic service report

A document that records assessments and treatment designed to restore a patient’s ability to function.

Physical therapy

The use of physical agents, such as therapeutic exercise and thermal modalities, to restore function and promote healing following illness or injury.

PPR

Paper-based patient record; a format where most of the record is paper-based though some data may be stored on a computer.

EMR

Electronic medical record; a format where the entire medical record is stored in a computer.

Problem-Oriented Record (POR)

A medical record organized according to the patient’s health problems, allowing problems to be followed individually.

Subjective data

Data obtained from the patient, often included in SOAP progress notes.

Objective data

Data obtained by observation, physical examination, laboratory tests, and diagnostic tests.

Assessment

The physician’s interpretation of the patient's current condition based on subjective and objective data.

Plan

The proposed treatment for the patient as outlined in a SOAP progress note.

SOAP

An acronym for the format of progress notes in a POR: Subjective, Objective, Assessment, and Plan.

Chief complaint (CC)

The patient’s reason for seeking care; the symptom causing the patient the most trouble.

Family history

A review of the health status of a patient’s blood relatives focusing on familial diseases.

Familial disease

A condition that occurs in blood relatives more frequently than would be expected.

Social history

Information on a patient's lifestyle, health habits, and living environment, including education, occupation, and diet.

Review of Systems (ROS)

A systematic review of each body system by the physician to detect symptoms not yet revealed.

Medical records management

The process of creating, handling, and storing medical records.

Out guides

Supplies placed in the file to mark where a record has been removed.

Sorter

Equipment that facilitates placing documents or files in order.

Alphabetic Filing

A direct system of filing where the patient's legal name is used to locate the medical record.

Numeric Filing

An indirect method of filing where a number must be identified to access the patient's record.

Inactive records

Records of patients who have not been seen within the time period specified by the medical practice.