CHAPTER 10 HEALTH RECORD

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33 Terms

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age of majority

The age at which the law recognizes a person to be an adult; it varies by state.

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alphabetic filing

Any system that arranges names or topics according to the sequence of the letters in the alphabet.

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alphanumeric

Describes system made up of combination of the letters and numbers.

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anthropometric

Pertaining to the measurement of the size and proportions of the human body.

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caption

A heading, tittle, or subtitle under which records are filed.

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compliance

Meeting the standards and regulations of the practice’s established policies and procedures.

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computerized provider/physician order entry (CPOE)

The process of entering medication orders or other provider instructions into the EHR.

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concise

Using as few words as possible to express to express a message.

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continuity of care

The smooth continuation of care from one provider to another. This allows the patient to receive the most benefit with no interruption or duplication of care.

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dictation

To say something aloud for another person to write down.

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direct filling system

A filling system in which materials can be located without consulting another source of reference.

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electronic health record (EHR)

An electronic record that conforms to nationally recognized standards and contain health-related information about a specific patient. It can be created, managed, and consulted by authorize clinicians and staff from more than one healthcare organization.

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e-prescribing

The use of electronic software to communicate with pharmacies and send prescribing information. It takes the place of writing a prescription by hand and giving it to the patient; most new refill prescriptions can be submitted electronically, cutting down on fraud and errors.

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hereditary

Pass from parents to offspring through the genes.

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incidence

How often something happens occurs.

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interface

An interconnection between system.

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interoperability

The ability to work with other systems.

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numeric filing

The filing of records, correspondence, or cards by numbers.

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objective information

Data obtained through physical examination, laboratory and diagnostic testing and by measurable information.

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obliteration

To remove or destroy all traces of; do away with; destroy completely.

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out guides

Study cardboard or plastic file-size used to replace a folder temporarily removed from the filling space.

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parameters

Rules that control how something should be done; guidelines or boundaries.

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patient portal

A secure online website that gives patient 24-hour access to personal information using username and password.

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prognosis

The likely outcome of disease, including the chance of recovery.

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provisional diagnosis

A temporary made before all test results have been received.

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quality control

A process to ensure the reliability of test results, often using manufactured samples with known values.

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retention schedule

A method or plan of retaining or keeping health records and for their movement from active to inactive to closed.

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reverse chronologic

The most recent item is on top, and the oldest item is last.

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subjective information

Data or information obtained from the patient, including the patients feelings, perceptions, and concerns; this information is obtained through interviews or written questions.

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subsequent

Occurring later or after.

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tickler file

A chronologic file used as a reminder that something must be dealt with on a certain date.

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transcription

A type of written copy of dictated material.

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vested

Granted or endowed with a particular authority, right, or property; to have a special interest.