1. Chapter 7 Facility and Records Management
Review
Chapter 7
Facility and Records Management

2. 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

3. 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

4. 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.

5. 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

6. 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

7. 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)