Chapter 7 Facility and Records Management Review Chapter 7 Facility and Records Management

Review What would you start with on a computer-generated records? Begin with the patient's general information for billing and scheduling What does(can) HIPPA review with medical records? All safeguards, all documentation, and mandates that one person track health information in the medical office

Review What is the purpose of a medical record? It serves as a basis for planning care List some information included in the patients history file? Treatments, injuries, conditions of patients health This is extremely important to document every time a patient is seen? Date

Review This serves as a basis for planning patient care? A medical history What is POMR? Problem-oriented medical record What is POMR designed for? To establish a relationship between the patients profile, complaints, review of systems, physical examination, laboratory findings, and other relevant information What does POMR begin with? A standard data base Know S.O.A.P.

Review How many steps in filing? 5 What is the first step? Inspect What is the second step? Index the materials(by patients name) What is third step? Code for billing What is the forth step? Sort in alphabetical filing What is the fifth and final step? Storing- locate the file drawer, place the most recent material on top

Review This is the most common and simplest method of filling? Alphabetical This type of filing provides privacy? Numerical What is true with numerical filing? Most offices use the same number of digits for each number assigned, and the numbers are always filed in order from smallest to largest Progress note should be arranged in what order? Chronological What is chronological order? The most recent date on top

Review What is another name for chronological filing? Tickler file What is the main reason for a tickler file? To track follow-up appointment(ex: physicals, mammograms)