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health Information

Chapter 5

patient identification consists of the patients name and some other peice of identifying information such as medical record number, ssn
alias an assumed name
addressograph machine imprints patient identification information on each report
facility identification includes the name of the facility, mailing address, adn a telephone number
face sheet or admission/discharge record contain patient identification or demographic, financial data, and clinical data information
admitting diagnosis or provisional diagnosis the condition or disease for which the patient is seeking treatment
final diagnosis the diagnosis determined after evaluation and documented by the attenting physician upon discharge of the patient from the facility
uniform hospital discharge data set (UHDDS) the minimum core data set collectec on individual hospital discharges for the medicare and medicaid programs and much of this information is located on the face sheet
principal diagnosis condition established after study te be chiefly responsible for occasioning the admission of the patient to the hospital for care
secondary diagnosis additional conditions for whch the patient received treatment and/or impacted the inpatient care
comorbidities pre-existing/co-existing condition that will, because of its presence with a specific principal diagnosis, cause an increase in the patients length of stay by at least one day in 75% of all cases
complications additional diagnosis that describe conditions arising after the beginning of hospital observation and treatment and that modify the course of the patients illness or the medical care required: they prolong the patients length of stay by at leat one day in
principal procedure procedure performed for definitive or therapuetic reasons, rather than diagnostic, or treat a complication, or that procedure which is most closely related to the pricipal diagnosis
secondary procedures additional procedures performed during inpatient admission
attestation statement verified diagnoses and procedures documented and coded at discharge
upcoding or maximizing codes or DRG creep documentation of diagnoses and procedures that result in higher payment for a facility
advance directive notification form signed by the patient as proof they were notified of their right to have an advance directive
advance directive a legal document in which patients provide instructions as to how they want to be treated in the event they become very ill and there is no reasonable hope for recovery
informed consent the process of advising a patient about treatment options and depending on state laws, the provider may be obligated to disclose a patients diagnosis, proposed treatment/surgery, reason for the treatment/surgery, possible complications, likelihood of succ
consent to admission or conditions of admission is a generalized consent that documents a patients consent to receive medical treatment at the facility
patient property form records items patients bring with them to the hospital
certificate of birth or birth certificate is a record of birth information about the newborn patient and the parents and it identifies medical information regarding the pregnancy and birth of the newborn
certificate of death or death certificate contains a record of information regarding the decedent, his or her family, cause of death, adn the disposition of the body
emergency record documents the evaluation adn treatment of patients seen in the facilitys emergency department for immediate attetion of urgent medical conditions or traumatic injuries
anti-dumping legislation or (EMTALA) prevents facilities licensed to provide emergency services from transferring patients who are unable to pay to other institutions adn it requires that a patients condition must be stablilized prior to transfer
ambulance report generated by emergency medical technicians to document clinical information such as vital signs, level of consciousness, appearance of the patient, and so on
short stay an uncomplicated hosptial stay of less than 48 hours
discharge summary or clinical resume provides information for contiunity of care and facilitates medical staff committee review; it can also be used to respond to requests from authorized individuals or agencies
history documents the patients chief complaint, history of present illness, past/family/social history, and review of systems
interval history documents a patients 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
physical examination an assessment of the patients body systens to assist in determining a diagnosis, documenting a provisional diagnosis, and which may also include differential diagnoses
differential diagnosis indicates that several diagnoses are being considered as possible
consultation is the provision of health care services by a consulting physician whose opinion or advice is requested by another physician
consultation report is docmunented by the consultant and includes the consultants opinion adn findings based on a physical examination adn review of patient records
physician orders or doctors orders direct the diagnostic and therapeutic patient care activities
progress notes contain statements related to the coures of the patients illness, response to treatment, and status of discharge
integrated progess notes which means all progress notes documented by physicians, nurses, physical therapists, occupational therapists and other professional staff members are organized in the same section to the record
anesthesia record required when a patient receives an anesthetic other than a local anesthetic to document patient monitoring during administration of anesthetic agents and other activities related to the surgical episode
operative record describes gross findings, organs examined, adn techniques associated wtihe the performance of surgery
pathology report or tissue report assists in the diagnosis and treatment of patients by documenting the analysis of tissue removal surigcally or diagnostically or that expelled by the patient
macroscopic gross examination of tissue; visible to the naked eye
recovery room record delineates are administered to the patient from the time of arrival until the patient is moved to a nursing unit
ancillary reports documented by such departments as laboratory, radiology, nuclear medicine, and so on; they assist physicians in diagnosis and treatment of patients
nursing documentation plays a crucial role in patient care because teh majority of care delivered to inpatients is performed by nursing staff, which includes RN, LPN, and CNA
obstetrical record the mothers record and contains sn antepartum report, labor and delivery record, and postpartum record
neonatal record is the newborns record and contains a birth history, newborn identification, phyical examination, and progress notes
antepartum record or prenatal record started in the physicians office and includes health history of the mother, family, and social history, pregnancy risk factors, care during pregnancy includes tests performed, medications administered
labor and delivery record records progress of the mother from time of admission through time of delivery
postpartum record documents information concerning the mothers condition after delivery
birth history documents summary of pregnancy,labor and delivery, and newborns condition at birth
newborn identification immediatley following birth, footprints and fingerprints of the newborn are created and a writst or ankle band is placed on the newborn; within 12 hours of birth an identification form is also used to document information aout the newborn and mother
newborn physical examination an assessment of the newborns condition immediatley after birth, including time and date of birth, vital signs, birth weight and length, head and chest measurements, general appearance, and phyisical findings is completed
newborn progress nots documents information gathered by nurses in the nursury and includes vital signs, skin color, intake and output,weight, medications and treatments and observations
APGAR score measures the babys appearance A-skin color, P-grimace G-irritablility A-muscle tone and motion R-respirations on a scale of 1-10 with up to two points assigned for each measurement adn 10 being the max score
autopsy or necropsy ia an examination of a body after death that includes the macroscopic examination of vital organs adn tissue specimens to assist in determining a cause of death adn the character or extent of changes produced by disease
provisional autopsy report contains a cause of death, is to be documented within 72 hours
autopsy report or necropsy report or postmortem report may take up to 60 days, and contains summary of patients clinical history including diseases, surgical history, and treatment; detailed results of the macroscopic and microscopic findings including external appearance of the body and internal examination
ambulatory records or hospital outpatient records include a patient registration form similar to the inpatient face sheet, and depending on the complexity of the outpatient services provided, additional reports include ancillary reports, progress notes, physician orders, operative reports, pathology repo
short stay record allows providers to record the history, phyicial examination, progress notes, physician orders, and nursing documentation on one double sided form
uniform ambulatory care data set (UACDS) is the minimum core data set collected on medicare and medicaid outpatients
outpatient visit is the visit of a patient on one calendar day to one or more hospital departments for the purpose of receiving outpatient health care services
encouter a professional contact between a patient and a provider who delivers services or is professionaly responsible for services delivered to a patient
ancillary service visit or occasion of service is the appearance of an outpatient to a hospital department to receive an ordered service, test, or procedure
licensed practioner is requiered to have a public license/certification to deliver care to patietns, and a practioner can also be a provider
non-licensed practioner does not have a public license/certificate and is supervised by a licensed/cerified professional in the delivery of care to patients
primary diagnosis reason the patient sought out treatment during that encoutner
physician office records should contain patient registration information, a problem list, a medication record, progress notes and results of the ancillary reports
encouter form or superbill or free slip commonly used in physician offices to capture charges generated during an office visit and consists of a single page that contains a list of common services provided in the office
forms committee or patient record committee established to oversee this process and to approve forms used in the record
health care proxy or durable power of attorney legal document in which the patient chooses another person to make treatment decisions in the event the patient becomes incapable of making these decisions
chief complaint patients description of medical condition stated in the patients own words
history of present illness chronological description of patients present condtion from time of onset to present HPI should include location, quality, severity, duration of the condition, and associated signs and symptoms
past history summary of past illness, operations, injuries, treatments, and known allergies
family history a review of the medical events in the patients family including diseases that may be hereditary or present a risk to the patient
social history an age appropriate review of past and current activities such as daily routine, dietary habits, exercise routine, marital status, occupation, sleeping patterns, smoking, use of alcohol and other drugs, sexual activities
medications a listing of current medications and dosages
review of systems inventory by systems to document subjective symptoms stated by the patient. Provides an opportunity to gather information that the patient may have forgotten to mention or that may seem unimportant
discharge order the final physician order documented to release a patient from a facility
against medical advice (AMA) patients who sign themselves out of a facility and sign a release from responsibility for discharge
routine order physician orders preapproved by the medical staff, which are preprinted and placed on a patients record
standing order physician orders preapproved by the medical staff that direct the continual administration of specific activities for a specific period of time as a part of the diagnostic or therapeutic care
stop order or automatic stop order as a patient safety mechanism state law mandates and in the absence of state law facilities decide for which circumstances preapproved standing physician orders are automatically discontinued requiring the physician to document a new order
telephone order a verbal order dictated via telephone to an authorized facility staff member
telephone order call back policy requires the authorized staff member to read back and verify what the physician dictatedto ensure that the order is entered accurately
RAV (read and verified) abbreviation entered by the staff member who documents a telephone order to document that the telephone order call back policy was followed
transfer order a physician order documented to transfer a patient from one facitliy to another
verbal order orders dictated to an authorized facility staff member because the responsible physician is unable to personally document the order
voice order a verbal order dictated to an authorized facility staff member by the responsible physician who also happens to be present
written order orders that are handwritten in a paper-based record or entered into an electronic health record by the responsible physician
admission note progress note documented by the attending physicisn at the time of patient admission. Includes reason for admission including description of patients condition, brief history of present illness, patient care plan, method/mode of arrival, patients respons
follow up progress note daily progress notes documented by the responsible physicians. Includes patients condition, findings on examination, significant changes in condition and/or diagnosis, response to medications administered, response to clinical treatment, abnormal test fin
discharge note final progress note documented by the attending physician. Includes patients discharge destination, discharge medications, activity level allowed, and follow up plan
case management note progress note documented by a case manager. Outlilnes a discharge plan that includes case management/social services provided and patient education
dietary progress note progress note documented by the dietician. Includes patients dietary needs and any dietary observations made by staff
rehabilitation theraphty progress note progress notes documented by various rehabilitation therapists that demonstrate the patients progress toward established therapy goals
respiratory theraphy progress note progress notes documented by respiratory therapists. Include therapy administration, machines used, medications added to machines, type of therapy, dates/time of administration, specifications of the prescription, effects of therapy including any adverse
preanesthesia evaluation note progress notes documented by the anesthesiologist prior to the induction of anesthesia. Includes evidence of patient interview to verify past and present medical and drug history and previous anesthesia experience, evaluation of the patients physical sta
postanesthesia note progress notes documented by the anesthesiologist. Includes patients general condition following surgery, description of presence or absence of anesthesia related complications and/or postoperative abnormalities, blood pressure, pusle, presence/absence o
preoperative note progress notes documented by the surgeon prior to surgery. summarizes the patients condition and documents a preoperative diagnosis
postoperavtive note protress note documented by the surgeon after surgery. documents the patients response to surgery and postoperative diagnosis
nursing care plan documents nursing interventions to be used to care for the patient
nurses notes documetns daily observation about patients including initial history of the patient, reaction to treatments, and treatmetns rendered
nursing discharge summary documents patients discharge plans and instructions
graphic sheet documents patients vital signs using a graph for easy interpretation of data
medication administration record (MAR) documents medications administered, date and time of administration, name of drug, dosage, route of administration, and initials of nurse administering the medication
bedside terminal system computer system located at the patients bedside, which is used to automate nursing documentation. Patient information can be entered, stored, and retrieved adn displayed
Created by: dtrogdon6244