Save
Busy. Please wait.
Log in with Clever
or
show password
Forgot Password?
Don't have an account?  Sign up 
Sign up using Clever
or
Username is available taken
show password


Make sure to remember your password. If you forget it there is no way for StudyStack to send you a reset link. You would need to create a new account. Your email address is only used to allow you to reset your password. See our Privacy Policy and Terms of Service.

Already a StudyStack user? Log In

Reset Password
Enter the associated with your account, and we'll email you a link to reset your password.
focusNode
Didn't know it?
click below
 
Knew it?
click below
Don't Know
Remaining cards (0)
Know
0:00
edit
Embed Code - If you would like this activity on your web page, copy the script below and paste it into your web page.

  Normal Size     Small Size show me how

Blesi8e Ch26 Terms

[MO1] The Medical Record [Tier 01]

TermDefinition
audit inspection
charting process that lays out a chronological account of the patients treatment as well as the need for further follow-up
chief complaint noted in the patient's medical record as the main reason for the patient's visit
CHEDDAR acronym that provides a structured charting method for data acquired during a routine health care visit
chronologic refers to filing according to date
documentation both the act of preparing and the evidence created when a health care professional records information regarding a patient assessment and treatment
ethnicity demographic term that indicates what societal group a patient identifies with
history physical impression plan (HPIP) a similar system to SOAP of recording medical information about a patient
indexing a system of cross-referencing information contained in office files so that the data may be searched using different characteristics
meaningful use a term used by government agencies for improving patient care and outcomes through evaluating treatment patterns and necessity of treatment
objective information that can be observed; vital signs, lab results, diagnostic test results
privacy officer the person designated by a health care organization who handles and oversees the maintenance of protected health information
problem-oriented medical record (POMR) a system used to collect specific pieces of information regarding a patient during a health care visit.
progress notes record of continuing progress and treatment of a patient
purge to clean out; purge files of those patient who are no longer being seen by the provider
subjective information supplied by the patient regarding routine information about the patient, personal, medical and family history as well as their chief complaint.
SOAP one fo the most widely used methods of charting to collect patient encounter information
tickler file a chronological file commonly used as a follow-up method for a particular date.
Created by: MaesterRay
Popular Medical sets

 

 



Voices

Use these flashcards to help memorize information. Look at the large card and try to recall what is on the other side. Then click the card to flip it. If you knew the answer, click the green Know box. Otherwise, click the red Don't know box.

When you've placed seven or more cards in the Don't know box, click "retry" to try those cards again.

If you've accidentally put the card in the wrong box, just click on the card to take it out of the box.

You can also use your keyboard to move the cards as follows:

If you are logged in to your account, this website will remember which cards you know and don't know so that they are in the same box the next time you log in.

When you need a break, try one of the other activities listed below the flashcards like Matching, Snowman, or Hungry Bug. Although it may feel like you're playing a game, your brain is still making more connections with the information to help you out.

To see how well you know the information, try the Quiz or Test activity.

Pass complete!
"Know" box contains:
Time elapsed:
Retries:
restart all cards