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Mod A Unit 3 Terminology
Communication/Medical Records
65
Health Care
Not Applicable
11/30/2012

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Cards

Term
active listening
Definition
Occurs when a listener maintains eye contact and provides responses to the speaker.
Term
adjective
Definition
A word used to describe a noun or pronoun.
Term
adverb
Definition
A word used to describe a verb, adjective, or another adverb.
Term
body language
Definition
Nonverbal signals using body motions
Term
communication
Definition
The exchange of information between a sender and receiver.
Term
Conjunction
Definition
A word used to join words or groups of words.
Term
distracter
Definition
Something that cuases the sender or receiver not to give full attention to the message.
Term
fax (faxsimile)
Definition
Method of communication in which written material is converted into electronic impulses transmitted by telephone lines.
Term
feedback
Definition
Verbal or nonverbal indication that a message was received.
Term
grammar
Definition
Study of words and their relationship to other words in a sentence.
Term
interjection
Definition
A word used to express strong feelings or emotion.
Term
nonverbal
Definition
Without using words.
Term
noun
Definition
A word used to name things, including people, places, objects, and ideas.
Term
passive listening
Definition
Hearing what the speaker is saying but not fully concentrating on the conversation.
Term
prejudice
Definition
Negative opinion toward and individual because of the individual's affiliation with a specific group.
Term
preposition
Definition
A word used to begin a prepositional phrase.
Term
pronoun
Definition
A word used to take the place of a noun.
Term
punctuation
Definition
Marks within and between sentences that separate, emphasize, and clarify the different ideas within a sentence or group of sentences.
Term
sentence
Definition
Group of words that express a complete thought.
Term
stereotyping
Definition
Holding the belief that all members of a culture or group are the same.
Term
subject
Definition
Part of a sentence that identifies who or what is being discussed.
Term
verb
Definition
A word in a sentence that expresses action or a state of being.
Term
holistic
Definition
Involving all health needs of the patient, including physical, emotional, social, economic, and spiritual needs.
Term
litigation
Definition
A lawsuit
Term
maturation
Definition
Growth and developmental process involving a person's physical, social, and emotional functioning.
Term
rapport
Definition
Harmonious relationship that considers both the physical and the emotional needs of those involved.
Term
acronym
Definition
Word formed from the first letter of several words.
Term
active files
Definition
Current patient files.
Term
aging labels (year labels)
Definition
Labels on a chart that identify the year.
Term
alphabetical filing
Definition
Filing method that uses the alphabet to determine how files are arranged.
Term
caption
Definition
Words that describe the contents, name, or subject matter on a label.
Term
charting
Definition
Process of documenting events and services concerning a patient's care.
Term
coding
Definition
Process of underlining a keyword to indicate how a document should be filed.
Term
conditioning
Definition
Process of removing staples and paper clips and mending a document before filing.
Term
continuity of care
Definition
Care of the patient rendered by health care providers, w/the medical record documenting all treatment.
Term
cross-reference
Definition
Norigication system showing a file stored in more than one place.
Term
database
Definition
Information source and storage
Term
direct filing
Definition
Filing system that requires knowing only the patient's name to initiate or locate the file.
Term
electronic medical record (EMR)
Definition
Patient medical records kept in a computer file.
Term
entry
Definition
Written description of care provided to the patient.
Term
filing
Definition
Process of putting documents in a folder.
Term
guides
Definition
Dividers used to separate file folders.
Term
inactive files
Definition
Files of patients who have not been seen within a certain time span set by the medical practice.
Term
indexing
Definition
Process of determining how a record will be filed.
Term
indirect filing
Definition
Numerical filing system that requires a list containing cross-references of numbers and names to locate a file.
Term
key unit
Definition
First unit to be filed.
Term
labels
Definition
Stickers or other items that identify contents in a folder.
Term
medical record
Definition
Patient record that contains information about the patient's treatment history.
Term
numerical filing
Definition
Method of arranging files using numbers.
Term
objective
Definition
Concrete and factual; can be seen or measured.
Term
out guides
Definition
Separators that replace a file folder when it is removed from the file cabinet; contains a notation of the date & person who signed out the file.
Term
plan
Definition
Action created to solve a problem, as in a patient treatment plan.
Term
problem list
Definition
List of a patient's medical complaints.
Term
problem-oriented medical record (POMR)
Definition
Chart format that is arranged according to a patient's health complaint.
Term
progress notes
Definition
Data concerning a patient's medical care and its results.
Term
provider
Definition
Health care facility or the personnel rendering medical treatment to a patient.
Term
purge
Definition
To clean out.
Term
releasing
Definition
Marking or placing initials on a document to indicate it can be filed.
Term
SOAP
Definition
Type of chart format that dicides each patient problem into subjective and objective data, assessment and plan for treatment.
Term
sorting
Definition
Arranging documents in a particular order for filing ease.
Term
source-oriented format
Definition
Chart format that has dividers that separate the different types of patient information.
Term
subjective
Definition
Information supplied by the patient that cannot be proven.
Term
terminal-digit filing
Definition
Method of filing that organizes records by their final digits.
Term
tickler file
Definition
Reminder aid that organizes events by date.
Term
work-related injury
Definition
Injury that has occurred to an employee when performing the duties of his or her job.
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