Chapters 10 & 11 Study Guide: Medical Records and Business Correspondence

Vocabulary practice flashcards generated from the Chapter 10 & 11 study guide covering medical records documentation and business correspondence.

Complete, accurate, and concise documentation

Creates a clear record that can show appropriate care was provided.

Allergies

These belong in the health history, not on the basic registration form.

Informed consent forms

Record that the patient understands the treatment choices and the risks connected with them.

Financial information regarding payments

Keep payment history separate from the clinical record.

Allergies and current medications

Both are included in the health history because they affect safe treatment.

Documentation

All information recorded in a patient's chart.

Patient's own words

Write what the person says exactly, especially when describing symptoms.

POMR

Organizes the chart by each health problem using a database, problem list, plan, and progress notes.

Current

This is not one of the six Cs used to judge good charting.

Written release of information

Permission must be on paper; an oral statement is not enough.

Neatness/legibility

Typed or transcribed records reduce problems caused by hard-to-read handwriting.

All record types

Lab reports, provider notes, assistant notes, and health histories may be updated when the proper correction method is used.

Objective data

Facts that can be seen or measured, such as a temperature or laboratory result.

Subjective data

Information based on what a person reports, feels, thinks, or notices.

Source-oriented medical records

Groups information by where it came from, such as lab, nursing, or provider notes.

FH

The approved abbreviation used when recording family health background.

Transcription

Turning spoken or dictated notes into an accurate written form.

Keep and document outside test results

Place a copy in the chart and record that the patient brought it for the provider to review.

Reports from other physicians

The current office cannot send another office's records unless the patient specifically requests them.

Mother and father

When divorced parents both have custody, either parent may sign for the child.

All patients' records

Privacy protection applies to adults, children, people lacking capacity, and healthcare professionals.

Vital signs

These are measured during care and do not belong on the health-history form.

Informed consent forms (Procedure risks)

Confirm that participation is voluntary and that choices and procedure risks were explained.

Severity and onset of disease

The present-illness history describes when symptoms began, how serious they are, how long they last, and how they have changed.

Continuity of care

Helps everyone involved understand what has already happened and what the patient needs next.

All patient-care information must be documented

Phone calls, refills, consultation reports, and follow-up reports all belong in the chart.

Personal opinions or thoughts

Do not add judgments, guesses, or unrelated comments about the patient.

Single-line correction

Cross out the mistake once so it remains readable, then initial, date, and enter the correction.

The practice

The physical chart is owned by the physician or office, while the patient has rights to the information.

Transcription (Process)

The process of changing spoken notes into correct written notes.

SOAP components

S is what the patient reports; O is measurable facts; A is the provider's judgment; P is the next treatment step.

Six Cs of charting

Use the patient's words, write clearly and completely, stay brief, arrange events by time, and protect privacy.

Release-of-records order

First get a newly dated signed authorization, then copy the allowed material, and finally confirm it arrived.

Documentation; noncompliant; informed consent; protected health information; medical record

Use these in order for recording care, not following medical advice, making an informed choice, protected personal health details, and the complete patient file.

Medical record; subjective; objective; release

Use these in order for the complete patient file, reported information, measurable facts, and sending information outside the office.

Subjective information

Feeling tired and nauseated is reported by the patient and cannot be directly measured.

Objective information (Blood Pressure)

A blood pressure of 160/95 mm Hg is a measured fact.

Objective information (Temperature)

A temperature of 102.4°F recorded during the visit is a measured fact.

No. 10 envelope

The standard business size used most often for office correspondence.

High-quality bond paper

A faint design visible when held to light indicates better-grade stationery.

Padded envelopes

Protect items that could break or be damaged during delivery.

8½ × 11 inches

The standard letterhead size used for ordinary business correspondence.

Written correspondence

Communication sent in the form of a business letter.

Inside address

Shows the recipient's name and mailing information exactly as it appears on the envelope.

Complimentary closing

The courteous ending before the signature, such as "Respectfully yours" or "Best regards."

Full-block style

Every line begins at the left margin, making the layout quick and easy to prepare.

Avoid wordiness

Keep sentences clear, direct, and short so the message is easy to understand.

Spell-check and grammar-check

Run both reviews after writing to catch basic language mistakes.

Editing

Checks whether names, dates, numbers, and other facts are correct.

Proofreading

Checks the finished document for layout, spelling, punctuation, and grammar mistakes.

Two inches from the bottom

Begin the mailing address at this distance so it sits correctly on the envelope.

Three folds

Fold the page into equal sections so it fits neatly inside a standard business envelope.

E-mail

This method is not automatically secure and requires approved safeguards before patient information is sent.

Annotating

Marking, highlighting, or writing notes to call attention to important information.

Business-letter sequence

Arrange sender details first, then the date and recipient details, followed by greeting, subject, message, closing, signature, and notations.

Incoming-mail sequence

Sort and open first, record next, add needed notes, and distribute last.

Mail services

Express gives guaranteed fast delivery; First-Class handles ordinary letters; Certified provides delivery proof; Priority sends heavier items quickly.

Letter styles

One format keeps everything left; another moves the date and closing right; a third omits the greeting and closing.

Parts of a business letter

Identify the letterhead, date, recipient address, greeting, subject, message, courteous ending, signature, initials, and attachment/copy notes.

Standard bond

Use this plain professional paper for the second page instead of repeating the letterhead.

Processing incoming mail

Follow this order: sort, open, record, mark important details, then deliver to the correct person.

Consent to e-mail communication

Get the patient's permission before sending health information electronically.

Professional image

Neat, well-written office documents help create trust and a strong impression.

Precedent

The correct spelling for something from the past that serves as an example or guide.

Modified-block with indented paragraphs

Place the date and closing near the center or right, and begin each paragraph inward from the margin.

Salutation

The greeting near the beginning, such as "Dear Honorable Jordan."

Identification line

Shows the writer's initials and the initials of the person who typed the letter.

Enclosures

Extra documents sent with the letter, such as a laboratory report or another form.

Registered mail

Provides extra security and tracking for items with significant worth.

Invoices

Bills are commonly sent using ordinary letter service.

Approved USPS abbreviations

Use official shortened state and address forms and type the mailing information clearly for optical scanning.

Pronouns

These words are usually lowercase unless they begin a sentence or are part of a proper name.

Hygiene

The correct spelling for practices that help maintain cleanliness and health.

Clarity

Make the meaning easy to understand; this should be the goal of every letter.

Passive voice

Can soften unpleasant news by focusing on what will happen instead of emphasizing who will do it.

Open punctuation

Use no mark after the greeting or the courteous ending.

Templates

Reusable wording for frequently written letters that can be adjusted for each situation.

Valuable items

Use the most secure postal service when mailing something important or costly.