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chapter 5

HIT 114 chapter 5

patient identification patient name, nad other pieces of information
alias an assumed name
addressograph machine imprints patient identification on each report
facility identification name of facility, address, telephone number on each report
face sheet admission/discharge record. containes patient information, financail date, clinical data, demographic data
admitting diagnosis provisional. condition or disease for which the patient is seeking treatment
final diagnosis diagnosis found after evaluation and documentationby the physcian
Uniform hospital discharge data set minimum core data set collected on the individual hospitaldischarges for the medicare and medicaid programs
principal diagnosis condition established after study
secondary diagnoses additional conditions for which the patient received treatment
comorbities pre existing condition
complications additional diagnosis that describe conditions arising after the beginning of the hospital stay
principal procedure procedure performed for the definitive or theraputic reasons, rather than the diagnostic purposes
secondary procedures additional procedures performed during inpatient stay
attestation statement verifies diagnoses and procedures documented and coded at discharge
upcoding, maximizing coeds documentation of procedures that require higher payment
advance directive notification form a form signed by the patient to dicument that the patient has been notified of their right to have an advance directive.
advance directive legal document in which patients provide instructions as to how they want to be treated in the event that they become very ill and there will be no hope for recovery
informed consent the process of advising a patient about treatment options
consent to admission generalized consent that documents a patients consent to receive medical treatment in the facility
patient property form records items that the patients brings with them to the hospital
certificate of birth is a record of birth information about the newborn patient and the parents
certificate of death contains a record of information reguarding the decedent, family, cause of death, and the disposition of the body
emergency record documents the evaluation and treatment of patients in the emergency room
ambulance report documents a record of treatment by EMT on the ambulance ride
anti-dumping legislation prevents facilities liscensed to provide emergency services from transfering patients who are unable to pay to other institutions, they must be stable before transfer.
discharge summary provides information for continuity of care and facilities medical staff committee review
history documents the chief complaint, history and patient info
interval history documents a [atients history of present illness and any pertinet changes and physical findings since the previous hostory within 30 days
physical examination an assesment of the patients body systems
differential diagnosis indicaties that several diagnoses are being considered as possible
consultation the provision of health care services by a consulting physcian whose opinion or advice is requested by another physcian
consultation report documented by the consultant and included the consultants opinion and findings based on a physcial exam
physcians orders direct diagnostic and theraputic patient care activities
health care proxy power of attorney, legal document giving power of attorney
DNR do not resuscitate
chief complaint- CC patients description of medical condition
history of present illness- HPI chronological description of patients condition
past history summary of past illnesses
family history review of family condition and illnesses
social history age approiate rewview of past and current activities
review of systems- ROS review of all body systems
dischare order final order documented for dischagre
AMA against medical advice
routine orders physcians orders preapproved by the medical staff and placed in record
atanding order orders for routine patients
stop order patient safety mechanism, under circumstances treatment or meds may need to be stopped
telephone order-TO verbal roder over the telephone to an authorized staff member
telephone call back order requires the authorized staff memeber to read the order back
RAV read and verified
Transfer order transfer patient from one facility to another
verbal order order through authorized staff member verbally
voice order VO dictatced by authorized staff member
written order orders are hand written and placed into electronic system
progress notes contain statements on the course of patients conditions and illness and at discharge time
integrated progress note all progress notes reported by doctores and nurses and other staff are organized together
admission note documented by attending physcian at time of admission
follow up progresss note daily progess notes by physcian
discharge progess note final note upon discharge
case managemtn note documented by case manager outlines discharge plan
dietary progress note outlines diet plan by dietitian
rehab therapy progress note documented by therapists
respiratory therapy progress note documented by respiratory therapist
preanesthesia evaluation note documented prior to medication
postanesthesia note after surgery
preoperative note condition before
postoperative after surgery
anesthesia record documents any anesthetic other than local
operative record describes findings, organs examined and techniques used during operation
pathology report documents the analysis of tissue removed and treatment
macroscopic gross large view
ancillary report documents by lab, radiology, and nuclear medicince departments
nursing documentation anything documented by the nurses
nurse care plan nursing interventions
nurse notes daily observation
nurse discharge summary discharge plan
graphic sheet vital signs
medication administration record documents medcation given
bedside terminal system computer system at bedside for automated documents
obstetrical record in the mothers record contains antepartum record
neonatal record newborns record
antepartum record shows health of nothers, family, pregnancy risk factors
labor and delivery record records progress of the mother from time of admission through delivery
postpartum record condition after delivery
birth history summary of pregnancy, labor and delivery and newborns condition
newborn identification footprints and fingerprints
newborn physical exam assesment of newborn, dob, vs, height and weight
newborn progress notes notes on newborn in nursery
autopsy exam of body after death
provisional autopsy report cause of death preliminary documentation 72 hours
autopsy report 60 days and gives exact cause for death
ambulatory records patient registration from similar inpatient face sheet
short stay record less than 48 hours
abmulatory care data sheet minimum core data collected for medicare and medicaid
outpatient visit only a one day stay
encounter professional contact between patient and provider
ancillary service visit appearance of outpatient to ahospital department to receive test that was ordered
liscensed practioner has a public liscense to deliever care to patients
non liscensed practictioner doesnt have public liscense and is supervised by a liscensed practioner
formas committee established to oversee this process and approve formas that are used in the record
Created by: ashbug207