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Ch 6 Key Terms
3-2-1 Code It!
| Question | Answer |
|---|---|
| ambulatory care | see outpatient care |
| ambulatory patient | patient who is treated and released the same day and who does not stay overnight in the hospital |
| ambulatory surgery patient | patient who undergoes procedures that can be performed on an outpatient basis, with the patient treated and released the same day |
| clinic outpatient | patient who receives schedules diagnostic and therapeutic care |
| Data Elements for Emergency Department Systems (DEEDS) | collection of data reported by hospital-based emergency departments for the purpose of reducing incompatibility in emergency department records |
| Diagnostic Coding and Reporting Guidelines for Outpatient Services | developed by the federal government and approved for use by hospitals and providers for coding and reporting hospital-cases outpatient services and provider-based office visits |
| emergency care patient | patient treated for urgent problems and either released the same day or admitted to the hospital as an inpatient |
| first-listed diagnosis | diagnosis, condition, problem, or other reason for encounter/visit documented in the patient record to be chiefly responsible for the services provided |
| inconclusive diagnosis | see qualified diagnosis |
| observation patient | patient who receives services furnished on a hospital's premises that are ordered by a physician, including use of a bed and periodic monitoring by nursing or other staff, and that are reasonable and necessary to evaluate the outpatient's condition. |
| Outcome and Assessment Information Set (OASIS) | core set of comprehensive assessments for adult home care patients used to measure patient outcomes for outcome based quality improvement (OBQI) |
| outpatient | see ambulatory patient |
| outpatient care | any health care service provided to a patient who is not admitted to a facility |
| preadmission testing (PAT) | occurs after a surgical patient registers with a facility's admitting department, who the patient undergoes preoperative nursing assessment and receives preanesthesia evaluation by an anesthesiologist |
| primary care | acute care and preventive services provided as outpatient care and referred to as the point of first contact |
| primary care provider | manages and coordinates the patient's care, including referring the patient to a medical specialist for consultation and a second opinion |
| qualified diagnosis | diagnosis documented as probable, suspected, questionable, rule out, or working diagnosis |
| referred outpatient | patient who receives diagnostic or therapeutic care because such care is unavailable in the primary care provider's office |
| triage | organized method of identifying and treating patients according to urgency of care required |
| Uniform Ambulatory Care Data Set (UACDS) | established by the federal government as a standard data set for ambulatory care facility records |
Created by:
Cristinacholi
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