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MANAGING HEALTH
INFORMATION
Chapter 4
© 2012 THE MCGRAW-HILL COMPANIES, INC. ALL RIGHTS RESERVED
LEARNING OUTCOMES:
WHEN YOU FINISH THIS CHAPTER YOU WILL BE ABLE TO
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4.1 Classify various uses of computer technology.
4.2 Recall reasons for maintaining a medical chart and documents that
compile the medical chart.
4.3 Identify components of a paper-based medical record and explain how
the same components will be compiled in an electronic health record
format.
4.4 Distinguish among active, inactive, and closed files.
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4-3
LEARNING OUTCOMES: WHEN YOU FINISH THIS CHAPTER YOU WILL BE ABLE
TO (CONTINUED)
4.5
Differentiate among records management systems that may
be used in a medical office
4.6
Discuss the advantages and challenges of electronic health
records implementation
4.7
List three medical abbreviations not to be used that have
been targeted by JACHO
4.8
Discuss various input technologies used to create medical
documentation
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KEY TERMS
accession book
closed files
active files
coding
AHIMA
alphabetic filing
e-mail
inactive files
family history (FH)
indexing
color-coding
file server
folders
application software
cross-reference
sheet
database
inspecting
documents
internet
graphics application
label
ARMA
dead storage
guide
laptop
assessment
diagnosis (Dx)
history of present
illness (HPI)
lateral files
CHEDDAR
electronic health
records (EHR’s)
impression
mainframe
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KEY TERMS (CONTINUED)
medicolegal
objective
password
records
management
micrographics
online
past medical history
(PMH)
releasing
minicomputer
open-shelf files
personal computer
retention
mobile-aisle files
operating
system
physical exam (PE)
review of
systems
(ROS)
networking
out guide
plan
rule out (RO)
numeric filing
output device
problem oriented
medical record
(POMR)
© 2012 THE MCGRAW-HILL COMPANIES, INC. ALL RIGHTS RESERVED
KEY TERMS (CONTINUED)
social history (SH)
subjective
sorting
supercomputer virus
spreadsheet
tab cuts
voice-recognition
technology
programs
tabs
wireless
communication
storing
template
word processing
subject filing
transcription
program
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vertical files
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KEY TERMS
accession book --a book of consecutive numbers indicating the next
available number to be assigned
active files -- pertaining to current patients
AHIMA -- exists to serve health information management
professionals. The organization offers credentials such as
Registered Health Information Administrator
alphabetic filing -- the arrangement of names, titles, or
classifications in alphabetic order
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KEY TERMS (CONTINUED)
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application software --includes word processing, graphics,
spreadsheet, and database management software, applies the
computer’s capabilities to specific applications
ARMA -- the organization is to set standards for the filing and
retention of records
assessment -- used interchangeably with the terms diagnosis (Dx)
and impression and gives a name to the condition from which the
patient is suffering
CHEDDAR -- format also breaks down the components of a patient
encounter into seven detail-oriented sections: chief complaint,
history, exam, details of problem, drugs/dosages, assessment,
and return information
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KEY TERMS (CONTINUED)
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closed files -- those of patients who have died, moved away, or
terminated their relationship with the physician
coding -- is the placing of a number, a letter, or an underscore
beneath a word to indicate where the document should be filed
color-coding – Each letter of the alphabet is a different color
cross-reference sheet -- prepared to indicate where the original
material is filed and where in the files other copies may be found
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KEY TERMS (CONTINUED)
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database -- are collections of related data
dead storage -- a storage area separate from the area where active
files are kept
diagnosis (Dx) -- gives a name to the condition from which the
patient is suffering
electronic health records (EHRs) -- the assimilation and
interoperability (electronic systems working together) of various
healthcare databases compiled over the course of different
patient encounters
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KEY TERMS (CONTINUED)
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e-mail -- a telecommunications system for exchanging written
messages through a computer network
family history (FH) - - Facts about the health of the patient’s parents,
siblings, and other blood relatives that might be significant to the
patient’s condition
file server -- stores the computer programs and data to be shared by
all the computers in the network
folders -- hold the items that are filed
graphics application -- allow the user to create illustrations from
scratch electronically. Others are designed to mix and match
already created images, text, video, sound, and animation
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KEY TERMS (CONTINUED)
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guide -- rigid dividers placed at the end of a section of files to
indicate where a new section or category of files begins
history of present illness (HPI) -- Information about the symptoms
troubling the patient—location, quality, severity, timing, duration,
context, modifying factors, and any associated signs and/or
symptoms
impression -- gives a name to the condition from which the patient
is suffering
inactive files -- related to patients who have not seen the physician
for 6 months or longer
indexing -- is the mental process of selecting the name, title, or
classification under which an item will be filed and arranging the
units of the title or name in the proper order
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KEY TERMS (CONTINUED)
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inspecting documents -- document should be in good physical
condition, and the information should be complete.
Internet -- is an enormous computer network that links computers
and smaller computer networks worldwide
Label -- Oblong pieces of paper, frequently self-adhesive
laptop -- physicians are using to enter patient data, research medical
resources
lateral files -- the drawers or shelves open horizontally and files are
arranged sideways, from left to right, instead of from front to
back
mainframe -- store massive databases, which many users can
access at the same time
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KEY TERMS (CONTINUED)
medicolegal -- providing documentation of medical care, and they
are admissible in a court of law.
micrographics -- miniaturized images of the records.
minicomputer -- are designed for single users, but many operate with
tens or even hundreds of terminals.
mobile-aisle files -- open-shelf files that are moved manually or,
more often, by a motor.
networking -- provides a means of communicating, exchanging
information, and pooling resources among a group of computers
numeric filing -- one in which each patient is assigned a number.
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KEY TERMS (CONTINUED)
objective -- The physician’s examination of the patient contained in the SOAP
record; results of the examination may be shown under the heading
“Physical Examination (PE).”
online -- connected to a computer network for purposes of communicating,
gathering, or exchanging information.
open-shelf files -- Shelves that hold files, may be adjustable or fixed.
operating system -- The internal programming that tells the computer how
to use its own components by controlling the basic functions of the
computer.
out guide -- A card placed as a substitute for a file folder; serves that
indicates that a file has been removed.
output -- Processed data sent back to the user by the computer.
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KEY TERMS (CONTINUED)
password -- A code assigned to a computer user as a security measure.
past medical history (PMH) – A listing of any illnesses a patient had in the
past.
personal computer -- A computer designed for one user.
physical exam (PE) -- complete examination of the patient in which findings
for each of the major areas of the body are stated.
plan -- The treatment, as stated in the SOAP record, listing prescribed
medication, instructions given to the patient, recommendation for
surgery or hospitalization.
problem oriented medical record (POMR) -- A patient record organized
around a list of the patient’s complaints or problems.
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KEY TERMS (CONTINUED)
records management -- The systematic control of the steps in the life of a
record.
releasing -- The indication, by initial or by some other agreed upon mark,
that a document has been inspected, acted upon, and is ready for filing.
retention -- The length of time that records are kept.
review of systems (ROS) -- The physician’s specific questions to the
patient about each of the body’s systems.
rule out (RO) -- A possible diagnosis that must be proved or “ruled out” by
further tests.
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KEY TERMS (CONTINUED)
social history (SH) -- Information that may be pertinent to treatment regarding
the patient’s marital history, occupation, interests, and eating, drinking,
smoking habits.
sorting -- The arrangement of documents in the order in which they will be
filed.
spreadsheet -- Software used for financial planning and budgeting.
programs -- Computer programs that apply the computer’s capabilities to
specific uses.
storing -- placement of an item in its correct place in a file; also called “filing.”
subject filing -- A system of document storing whereby the placement of
related material is alphabetic by subject categories.
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KEY TERMS (CONTINUED)
subjective -- The patient’s description of the problem or complaint
including symptoms.
supercomputer -- The most powerful computers available.
tab cuts -- Are to the positions of the tab.
tabs -- Are the projections that extend beyond the rest of the folder.
template -- A standard electronic version of a frequently used document.
transcription – The physician, or other provider of medical care, dictates
the medical data into a recording device, to be transcribed by a
keyboardist who specializes in medical data keyboarding.
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KEY TERMS (CONTINUED)
vertical files -- Drawer files, contained in cabinets of various sizes; files
are arranged from front to back.
virus -- is a program written with the intent of damaging another user’s
data, software, or computer.
voice-recognition technology -- A program used along with a word
processing application to transcribe spoken words into text without the
use of a keyboard.
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KEY TERMS (CONTINUED)
wireless communication– The use of radio waves rather than wires or
cables to transmit data through a computer network.
word processing -- Software used to enter, edit, format, and print
documents
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4.1 CLASSIFY VARIOUS USES OF COMPUTER TECHNOLOGY
Computer usage in a medical environment has increased
tremendously in recent years:
 Scheduling
 Medical data entry
 Communications
 Research
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4.2 RECALL REASONS FOR MAINTAINING A MEDICAL CHART AND
DOCUMENTS THAT COMPROMISE THE MEDICAL CHART
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Examples of documents that may be found in a
medical chart are:
— Chart notes.
— History and physicals.
— Clinical forms.
— Medical reports.
— Communications with the patient or with other medical personnel
concerning the patient.
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4.3 IDENTIFY COMPONENTS OF A PAPER-BASED MEDICAL RECORD
AND EXPLAIN HOW THE SAME COMPONENTS WILL BE COMPILED IN AN
ELECTRONIC HEALTH RECORD FORMAT
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 Notes from the patient encounter, such as the chief complaint,
history, examination, impression/diagnosis, and treatment plan
are documented in a patient medical chart using various
formats, such as SOAP.
 Electronic input.
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4.4 DISTINGUISH AMONG ACTIVE, INACTIVE, AND CLOSED FILES.
 Active files
 Inactive files
 Closed files
As each medical specialty has its own requirements, a retention
schedule should be developed by the practice based on its needs
and state statutes.
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4.5 DIFFERENTIATE AMONG THE RECORDS MANAGEMENT
SYSTEMS THAT MAY BE USED IN A MEDICAL OFFICE
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Records management is the systematic control of records from their
creation through maintenance to eventual storage or destruction.
Records may be managed electronically or manually (paper
records).
 Alphabetic filing
 Numeric filing
 Subject filing
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4.6 DISCUSS THE ADVANTAGES AND CHALLENGES OF ELECTRONIC
HEALTH RECORDS IMPLEMENTATION.
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The need to store large amounts of medical data and to protect that
data efficiently is a primary concern of the medical and
governmental communities. Mandatory implementation of
electronic health records (EHRs) is part of national healthcare
reform.
 Advantages of Electronic Health Records
 Challenges of Electronic Health Records
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4.7 LIST THREE MEDICAL ABBREVIATIONS THAT HAVE BEEN
TARGETED BY JACHO
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Similar medical abbreviations may contribute to a misdiagnosis or
misinterpretation. JACHO has distributed a listing of “Do Not Use”
abbreviations.
 U
 IU
 Q or q.
 MS
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4.8 DISCUSS THE VARIOUS INPUT TECHNOLOGIES USED TO CREATE
MEDICAL DOCUMENTATION.
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 Voice-recognition software
 Wireless technology
 Transcription
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