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medical records
chapter 2
| Term | Definition |
|---|---|
| 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
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