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Vocabulary 2
Vocab 2
Term | Definition |
---|---|
Abstracting | collection of data from the medical record for statistical and planning purposes. |
Analysis | Reviewing the medical record to determine that all required documentation is present including signatures and reports. |
Cancer registry | A database of patients diagnosed with cancer. |
Coding | Assignment of number to diagnose and/or procedures using the current edition of coding or classifications system such as the international classification of disease ( ICD ) or current procedural terminology |
Defiency slip | a document that identifies deficiencies in documentation. |
Healthcare provider | an individual or facility such as a hospital that provides healthcare to patient |
JCAHO | Joint commission on the accreditation of health organizations |
litigation | lawsuit |
Medical transcription | interpretation and typing of reports dictated by physicians and other healthcare personnel |
medicare | federal insurance for patients over 65 or for disabled |
Performance improvement | evaluating the overall performance of a healthcare facility from the environment to patient care with the purpose of continues improvement |
periodical | a magazine or journal published at specified periods for example weekly or monthly |
physician incomplete area | are of the health information management where physicians come to work on incomplete records |
Physician progress note | handwritten or typed entries made by physicians regarding the patients progress during hospitalization or other treatment |
risk management | addressing the risk to which patients visitors hospital staff medical staff vendors and others are exposed |
third party | a person or entity such as an insurance company other than healthcare facility or patient |