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medical records

chapter 2

abstracting collection of data from the medical record for statistical and planning purpose.
analysis reviewing the medical record to determine that all required documentation is present including signatures and reports
cancer registry a database of patients diagnose with cancer
coding assigning of numbers to diagnose and/or procedures using the current edition of a coding or classifiation system such as the international classification of diseases or current procedural
deficiency slip a document that identifies deficiencies in documentation
healthcare provider an individual of facility, such as hospital, that provides healthcare to patient.
JACHO joint commission on the accreditation of healthcare organization.
litigation lawsuit
medical record number a unique number assigned to a medical records to identify it.
medical transcription interpretation and typing of reports dictated by physician and other healthcare personnel.
medicare federal insurance for patients over 65 or for the disabled.
performance improvment evaluating the overall performance of a healthcare facility, from the environment to patient care, with the purpose of continuous improvement.
periodical a magazine or journals published at specified periods, for example, weekly or monthly.
physician incomplete area area of health information management department where physician come to work on incomplete records.
physician progress note handwritten or typed entries made by the physician regarding the patients progress during hospitalization or other treatment
risk management addressing the risk to witch patients, visitors, hospital staff, medical staff, vendors and others are exposed.
third party a person or entity, such as an insurance company, other than the healthcare facility of patient.
Created by: Smileyjelly