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Chp. 5 (HIT-114)Shan
key terms (flashcards)
| Question | Answer |
|---|---|
| Addresssograph machine | plastic card containing patient identification; used to imprint info. on ea. report in the patient record. |
| Admission note | progress note documented by the attending m.d. at the time of patient admission. |
| Admission/Discharge Record | (face sheet) contains patient identification( or demo-graphic), finanical, and clinical info (or data). normally filed in the beginning of the chart. |
| Admitting Dx | provisional dx-- working tentative, admission, & preliminary dx obtained from the attending phy.; it is the dx upon which inpatient care is initially based. |
| **advance directive** | legal document that provides instructions as to how patients want to be treated in the event they b/c very ill & there is no reasonalbe hope for recovery. |
| Advance directive notification form | Signed by the patient as proof they were notified of their right to have an advance directive. |
| Against Medical Advice (AMA) | Pt's who sign themselves out of a facility & sign a release from responsibility for discharge. |
| Alias | An assumed name. |
| Ambulance Report | generated by EMT--Emergency medical technicians to document clinical info. such as vital signs,level of consciosness, appearance of the pt. original record kept w/the ambulance company --copy goes to the ED--emergency dept. |
| Ambulatory Record | documents services recieved by a pt who has not been admitted to the hosp. overnight, & includes ancillary services, ED sevices, outpatient(or ambulatory) surgery; also called hospital ambulatory care record. |
| Ancillary Reports | documented by such departments as laboratory, radiology, nuclear medicine to assist physician in dx & treatment of pt's |
| Ancillary service visit | Appearance of an outpt. to a hosp. dept. to recieve an ordered service, test or procedure; also called occasion of service. |
| anesthesia record | required when a pt. recieves an anesthetic other than a local anesthetic to document pt. monitoring during administration of anesthetic agents and other activities related to the surgical episode. |
| antepartum record | gernerated in the physician's office which includes health hx of the mother,family & social hx, pregnancy risk factors, care during pregnancy including tests performed, & medications administered, also called prenatal record. |
| anti-dumping legislation | (EMTALA)-Emergency Medical Treatment & Labor Act:addressed the problem of hospitals failing to screen,treat,or appropriatly transfer patients (pt.dumping)by establishing criteria for the discharge & transfer of HMB & HMAB pt's also called the anti-dumping |
| APGAR score | Measures a baby's appearance(e.g.(A) skin color),pulse(P),grimace(G),(eg.,irritability), activity(A)(eg.,muscle tone & motion), & respirations (R) on a scale of 1 to 10(with up to 2 pts assigned for ea. measurement & 10 being the maximum score). |
| attestation statement | (5)signed by the attending physician to verify diagnonses & procedures documented & coded @ discharged of a hospital pt.;discontinued in 1995. |
| automatic stop order | stop order>as a pt. safety mechanism,state law mandates-standing physician orders are automatically discontinued(stopped),requiring the physician to document a new order. |
| autopsy | an examination of a body after death- to the determind cause of death. |
| autopsy report | To be documented within 60 days and contains summary of pt's clinical hx including diseases,surgical hx, & tx; detailed results. |
| bedside terminal system | Computer system located at the pt's bedside. Used to automate nursing documentation;patient information can be entered,stored retrieved, and displayed. |
| birth certificate | certificate of birth |
| birth history | documents summary of pregnancy,labor & delivery, and newborn's condition @ birth. |
| case management note | progress note documented by a case manager. Outlines a discharge plan that includes case management/social services provided & pt. education. |
| certificate of birth | Record of birth information about the newborn patient & the parents, & identifies medical information regarding the pregnancy & birth of the newborn; also called birth certificate. |
| certificate of death | Contains a record of information regarding the decedent, his or her family, cause of death, and the disposition of the body; also called death certificate. |
| chief compliant (CC) | pt.'s description of medical condition, stated in the pt.'s own words. |
| clinical data | Health information obtained throughout treatment & care of patient. |
| clinical resume | discharge summary |
| comorbidities | pre-existing condition that will, because of its presence with a specific prinicipal diagnosis, cause an increase in the pt's length of stay by at least on day 75% of the cases (e.g. dibetities, enemia) |
| **complications** | additional diagnosis that describe conditions arising after the beginning of hospital observation and treatment & that modify the course of the pt's illness or the medical care required; they prolong the pt's length of stay by at least one day. |
| condition of admission | consent to admission |
| consulation | Provision of health care services by a consulting physician whose opinion or advice is required by another physician. |
| consultation report | Documented by the consultant & includes the consultant's opinion & findings based on a physical examination & review of pt. records. |
| death certificate | certificate of death |
| dietary progress note | Progress note documented by the dietitian(or authorized designee) which includes pt's dietary needs & any dietary observation made by staff. |
| differential diagnosis | Indicates that several diagnoses are being considered as possible. |
| discharge note | Final progress note documented by the attending physician. Includes pt's discharge destination,discharge medications,activity level allowed, & follow-up plan. |
| discharge order | Final physician order documented to release a pt. from a facility. |
| discharge summary | Provides information for continuity of care & facilitates medical staff committee review; documents the pt's hospitalization, including reson(s) for hospitaliztion, course of treatment, and condition at discharge; also called clinical resume. |
| doctors orders | physician orders |
| DRG Creep | upcoding |
| durable power of attorney | health care proxy |
| emergency record | documents the evaluation & treatment of pt's seen in the facility's emergency department for immediate attention of urgent medical conditions or traumatic injuries. |
| encounter | Professional contact between a pt. & a provider who dilivers services or is professionally responsible for services delivered to a pt. |
| encounter form | Commonly used in physician offices to capture charges generated during an office visit & common services provided in the office. AKA superbill or fee slip. |
| face sheet | Contains pt's indentification (or demographic), financial, and clinical information (or data). |
| facility identification | name of the facility,mailing address,and a telephone number, included on each report. |
| family history | review of the medical events in the pt's family, including disease which may be hereditary or present a risk to the patient. |
| fee slip | encounter form |
| final diagnosis | Diagnosis determined after evaluation & documented by the attending physician upon discharge of the patient from the facility. |
| follow-up progress note | daily progress notes documented by the responsible physicians. includes pt's condition,findings on examination,significant changes in condition and/or diagnosis,respose to medications administered,response to clinical treatment,abnormal test finding,and t |
| forms comittee | Established to oversee the process of adding, deleting, and changing forms and to approve forms used in the record. |
| graphic sheet | documents patient's vital signs (e.g., temperture,pulse,respiration,blood pressure,and so on) using graph for easy interpretation of data. |
| health care proxy | Legal document (recognized by New York State) in which the pt. chooses another person to make treatment decisions in the event the pt. becomes incapable of making these decisions. |
| history | documents the pt's chief complaint,history of present illness (HPI),past/family/social history(PFSH) and review of systems (ROS). |
| history of present illness (HPI) | Chronilogical description of pt's present condition from time of onset to present; should include location,quality,severity,duration of the condition, and associated signs and symptoms. |
| informed consent | Process of advising a patient about treatment options and, depending on state laws, the provider may be obligated to disclosed a patient's diagnosis, proposed treatment/surgery,reason for the treatment/surgery,possible complications,likelihood of success, |
| intergrated progress notes | Progness notes documented by physicians,nurses,physical therapists,occupational therapists, and other professional staff members are organized in the same section of the record. |
| interval history | documents a pt's history of present illness and any pertinent changes and physical findings that occurred since a previous inpatient admission if the patient is readmitted within 30 days after discharge for the same condition. |
| labor and delivery record | Records progress of the mother from time of admission through time of delivery; infromation includes time of onset of contractions,severity of contractions,medications administered,patient and fetal vital signs, and progression of labor. |
| licensed practitioner | Required to have a public license/certification to deliver care to patients. |
| macroscopic | Gross examination of tissue; visible to the naked eye. |
| maximizing code | upcoding |
| medication administration record (MAR) | Documents medications administered,data and time of administration, name of drug,dosage,route of administration,and initials of nurse administering medication. |
| necropsy | the character or extent of changes produced by disease.(autopsy) |
| necropsy report | autopsy report |
| neonatal record | Newborn's record that contains a birth history,newborn identification,physical examination,and progress notes. |
| newborn identification | Immediately following birh,footprints and fingerprints of the newborn are created, and a wrist or ankle band is placed on the newborn(with an identical band placed on the mother). |
| newborn physical examination | An assessment of the newborn's condition immediately after birth, including time and date of bith, vital signs, birth weight and lenth, head and chest measurements,general appearance and physical findings. |
| newborn progress notes | Documents information gathered by nurses in the nursery and includes vital signs, skin color, intake and output, weight, medications and treatment, and observations. |
| non-licensed practitioner | Does not have a public license/certification and is supervised by a licensed/certified professional in the delivery of care to patients. |
| nures notes | Documents daily observation about patients, including an initial history of the patient, patient's reactions to treatments, and treatments rendered. |
| nursing care plan | Documents nursing diagnosis as well as interventions used to care for the patient. |
| nursing discharge summary | Documents patient discharge plans and instructions. |
| nursing documentation | Crucial to patient care because the majority of care delivered to inpatients is performed by nursing staff. |
| obstetrical record | Mother's record that contains an antepartum record, labor and delivery record, and postpartum record. |
| occasion of service | ancillary service visit(e.g. labs,ordered service,or procedure). |
| operative report | describes gross findings,organs examined(visually or palpated),and techniques associated with the performace of surgery.To be dictated or handwritten immediately following the operation and authenticated by the responsible surgeon. |
| outpatient visit | Visit of a patient on one calendar day to one or more hospital departments for the purpose of receiving outpatient health care services. |
| Past history | summary of past illnesses,operations,injuries,treatments, and known allergies. |
| pathology report | Assists in the analysis and treatment of patients by documenting the analysis of tissue removed surgically or diagnostically, or that expelled by the patients; also called tissue report. |
| patient identification | pt's name and some other piece of identifying information such as medical record number, date of birth,or social security number. |
| patient property form | Records items patients bring with them to the hospital. |
| patient record commitee | forms committee |
| phycial examination | Assessment of the pt's body systems to assist in determining a diagnosis, documenting a provisional diagnosis, which may include differential diagnoses. |
| physician office record | documents patient health care services recieved in a physician's office. |
| physician orders | Direct the diagnostic and therapeutic patient care activities; also called doctors orders. |
| postanesthesia note | Progress note documented by the anethesiologist. |
| postmortem report | autopsy report |
| postoperative note | Progress note documented by the surgeon after surgery.Documents the pt's response to surgery and a postoperative diagnosis. |
| postpartum record | Documents information concerning the mother's condition after delivery. |
| preanesthesia evaluation note | Progress note documented by the anesthesiologist prior to the induction of anesthesia. |
| prenatal record | antepartum record |
| preoperative note | Progress note documented by the surgeon prior to surgery. Summarizes the pt's condition and documents a preoperative diagnosis. |
| primary diagnosis | Reason the patient sought treatment during that encounter; reflects the current, most significant reason for services provided or procedures performed. |
| **principal diagnosis** | condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care. |
| **principal procedure** | Procedure performed for definitive or therapeutic reasons,rather than diagnostic purposes, or to treat a complication, or that procedure which is most closely related to the principal diagnosis. |
| progress notes | Contain statements related to the course of the patient's illness,response to treatment, and status at discharge. |
| provisional autopsy report | Contains a cause fo death and is to be documented within 72 hours(3days). |
| read and varified (RAV) | Abbreviation entered by staff member who documents a telephone order to document that the telephone order call-back policy was followed. |
| recovery room record | Delineates care administerd to the patient from the time of arrival until the patient is moved to a nursing unit. |
| rehabilitation therapy progress note | Progress notes documented by various rehabilitation therapists that demonstrated the pt's progress(or lack thereof)toward established therapy goals. |
| respiratory therapy progress note | Progress notes documented by respiratory therapists. |
| review of systems | Inventory by systems to reveal subjective symptoms stated by the patient; provides an opportunity to gather information that the patient may have forgotten to mention or that may have seemed unimportant. |
| routine order | Physician orders preapproved by the medical staff,which are preprinted and placed on a pt's record. |
| **secondary diagnosis** | additional conditions for which the patient received treatment and/or impacted the inpatient care. |
| **secondary procedure(s)** | additional procedure(s) performed during inpatient admission. |
| short stay | An uncomplicated hospital stay of less than 48 hours. |
| short stay record | Allows providers to record the patient's history, physical examination,progress notes,physician orders, and nursing documentation on one double-sided form. |
| social history | Age-appropriate review of past and current activities such as daily routine,dietary habits,excercise routine, marital status,occupation,sleeping patterns,smoking,use of alcohol and other drugs,sexual activities,and so on. |
| standing order | physician orders preapproved by the medical staff that direct the continual administration of specific acitivities for a specific period of time as a part of diagnostic or therapeutic care. |
| stop order | as a pt. safety mechanism,state law mandates, and in the absence of state law facilities decide,for which circumstances preapproved standing physician orders are automatically discontinued (stopped),requiring the physician to document a new order. |
| superbill | encoutner form |
| telephone order call back policy | requires the authorized staff member to read back and verify what the physician dictated to ensure that the order is entered accuratley. |
| tissue report | pathology report |
| transfer order | physician order documented to transfer a patient from one facility to another. |
| Uniform Ambulatory Care Data Set (UACDS) | Minimum core data set collected on Medicare oand Medicaid outpatients. |
| Uniform Hospital Discharge Data Set (UHDDS) | Minimum core data set collected on individual hospital dicharges for the Medicare and Medicaid programs; much of this information is located on the face sheet. |
| **upcoding** | documentation of diagnosis and procedures that result in higher payment for a facility;also call maximizing codes or DRG Creep. |
| verbal order | Orders dictated to an authorized facility staff member because the responsible physician is unable to personally document the order. |
| written order | Orders that are handwritten in a paper-based record or entered into an electronic health record by the responsible physician. |
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