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medical records

chapter 1 vocab

TermDefinition
indexing assigning a document to the correct patient document type and episode of care in an optical imaging system
loose documents documents received by the health information mangagment department after the patient has been discharged that must be placed in the record
medical record A multi-form document detailing the patients diagnosis diagnostic testing and treatment given during an encounter with the hospital portions of the record may be computerized
medical transcription interpretation and typing of records dictated by physicians and other healthcare personnel
misfile to file a record or document in the wrong location
scanning the process of converting a paper document into a computer image
operative report a report dictated by the surgeon detailing the surgical procedure and findings
assembly Arranging the documents of the medical record in a specific order after discharge of the patient
authorization a signed consent of the patient or his or her representative to release confidential information
compromised care to make the patients care less affective
contract service a company hired to perform a function when the health information management department is unable to manage the amount of work such as transcription of dictation
discharge summary A report dictated by a physician at the end of hospitalization that details the diagnosis and treatment given
health information management department the department in a health care facility responsible for maintaining security and confidentiality of the patients records for promoting responsible use of the record in the patients care
optical imaging system a computer system in which documents are converted to computer images that can be viewed simultaneously by multiple users
quality control Review of documents that have been scanned into an optical imaging system to insure that they are legible and have been indexed correctly
Created by: amywap
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