Help
Options
Didn't know it?
click below
click below
Knew it?
click below
click below
Don't Know
Remaining cards (0)
Know
retry
shuffle
restart
0:00
Embed Code - If you would like this activity on your web page, copy the script below and paste it into your web page.
Normal Size Small Size show me how
Normal Size Small Size show me how
Patient Record
Patient Record Vocabulary
| Question | Answer |
|---|---|
| abbreviation list | medical staff-approved abbreviations, acronyms, and symbols |
| addendum | amending an entry to the medical record to clarify or add additional information |
| administrative data | includes demographic, socioeconomic and financial information |
| administrative terminologies | primarily designed for statistical and epidemiological reports, reimbursement for healthcare services analysis of managerial processes and other secondary data aggregation and anlysis purposes; output systems. |
| alternate care facilities | providing behavioral health, home health, hospice, outpatient, skilled nursing, and other forms of care; also serve as a documentation source for patient care information |
| alternative storage method | such as off-site storage, microfilm or optical imaging |
| amending patient record | only the author of the original entry, draw line through entry, date, time and sign |
| archived records | records that are in storage and are rarely used |
| assessment | judgement, opinion, or evaluation made by the health care provider |
| ASTM E 1762 | Standard Guide for Authentication of Healthcare Information |
| audit trail | a list of all changes made to patient documentation, containing date, time and user who performed the transaction |
| authentication | an entry signed by the author |
| auto-authentication | involves authenticating a dictated report prior to its transcription, no consisten with proper authentication because it is done after transcription |
| automated record system | replaces paper-based records to provide timely access to health information |
| character | an electronic and/or digital letter, number or symbol |
| chart deficiencies | incomplete or delinquent charts, missing reports and other documentation or signatures |
| chronological date order | filing of patient information in order of first visit to completion of treatment |
| classification | system that groups together similar diseases and procedures and organizes related entities for easy retrieval |
| clinical data | includes all patient health information obtained throughout the treatment and care of patient |
| clinical data repository | allows for the collection of all clinical data in one centralized database, to provide easy access to data in electronic or printed form |
| coding | assigning of widely identified series of numbers or letters, for easy identification of illness, medical treatment or procedure |
| computer-based patient record (CPR) | same as electronic health record (EHR) |
| COSTAR | Computer Stored Ambulatory Record - outpatient electronic health records, created as Massachusetts General Hospital in 1960's with the goal of improving the availability and organization of outpatient records |
| conditions of participation (COP) | the report of physical exam must be placed in the patient record within 48 hours after admission |
| controlled clinical reference terminologies | clinical info that is captured in an electronic health record during the course of patient care, allowing the creation of detailed electronic clinical health records thru direct entry at the point of care |
| countersignature | form of authentication by an individual in addition tot he signature by the original author of an entry; required when documenting a telephone order taken from a physician |
| cryptography | uses an algorithm of two keys, one for creating the digital signature by transforming data into a seemingly unintelligible form and the other to verify a digital signature and return the message to its original form |
| database | contains a minimum set of data to be collected on very patient, serves as an overview of patient information |
| deficiency slip | is completed by the analysis clerk and is attached to the patient record to facilitate completion of record deficiencies |
| delinquent record | incomplete records are considered delinquent after 30 days, privilieges may be suspended until records are completed |
| delinquent record rate | divide the total number of delinquent records by the number of discharges in the period |
| demographic data | includes patient's name, date of birth, place of birth, mother's maiden name, social security number, etc. |
| diagnostic/management plan | plans to learn more about the patient's condition and the management of the condition |
| digital archive | a storage solution that consolidates electronic records on a computer server for management and retrieval |
| digital signature | created using public key cryptography to authenticate a document or message |
| document imaging | same as optical disk imaging |
| electronic health record (EHR) | medical records permanently stored on a disk, records are viewed on a monitor or as printout; famility designates their legal medical record as either electronic or paper-based; same as CPR |
| electronic medical record (EMR) | created on a computer using a keybaord, mouse, optical pen device, voice recognitions system, scanner or touch screen |
| electronic signature | term that refers to the various methods an electronic document can be authenticated, including name at the end of an email, image of handwritten signature, secret PIN, fingerprint or retinal scan or digital signature |
| field | a group of characters fors a field, a collection of related fields form a record |
| file | a collection of related records |
| heuristics | rules of thumb |
| hospital ambulatory care record | services received by a patient who has not been admitted to the hopstial, and includes ancillary services, emergency department services, and outpatient surgery; ambulatory = outpatient |
| hospital inpatient record | documents the care and treatment received by a patient admitted to the hospital |
| hospital outpatient record | documents the care and treatment received by a patient who is not admitted for treatment |
| ICD-03 | International Statistical Classification of Diseases for Oncology, Third Edition |
| inactive records | records placed in storage and rarely accessed; same as archived records |
| incident record | generated for patient and visitor accidents, providing a summary of an event for documentation purposes |
| independent database | contains clinical information created by researchers, typically in academic medical centers |
| indexed | indentified according to a unique identification number, such as patient record number |
| information capture | the process of recording representations of human thought, perceptions, or actions in documenting patient care, as well as device-generated information that is gathers, and/or computed about a patient as part of health care |
| initial plan | how the strategy for management of the patient's care is outlined |
| integrated record | arranges reports in strict chonological date order, or revers date order; allows for observation of how the patient is progressing and responds to treatment |
| interface | used in electronic health record systems for presentation to end users, to facilitate electronic data collection at the point of care |
| jukeboxes | store large numbers of optical disks, resulting in huge storeage capabilities |
| LOINC | Logical Observation Identifiers Names and Codes |
| longitudinal patient record | contains records from different episodes of care, providers and facilities that are linked to form a view, over time, of a patient's health care encounters (same as record linkage) |
| magnetic degaussing | alters magnetic fields on a computer medium |
| manual record | maintaining patient records in a paper format |
| mapping | the process of linking content from one terminology to another or to a classification |
| MHealth | refers to the use of wireless technology to enable health care professionals to make better quality decisions, while reduing cost of care and improving convenience to caregivers; provider can quickly update physician orders |
| microfilm | photographic process that records the original paper record to film, with the film image appearing similar to a photo negative |
| MIR | Medical Record Institute |
| NCVHS | National Committee on Vital and health Statistics |
| nomenclature | a recognized system of names |
| nursing assessment | documents the patient's history, current medications, and vital signs on a varity of nursing forms in the nursing unit, including nurses' notes, graphic charts, etc |
| objective | observations abou the patient, such as physical findings or lab/xray results |
| off-site storage | used to store records at a location separate from the facility |
| optical disk imaging | same as document imaging; provides an alterntive to traditional microfilm or remote storage systems, patient records are converted to an electronic image and save on storage media, using laser technology to creat the image |
| patient education plan | ancillary services provided by a a health care facility |
| patient record | the business record for a patient encounter, containing documentation of all health care services provided to a patient |
| patient's representative | the person who has legal responsibility for the patient, signs admission consent form to document consent to treatment, as well as other legal forms |
| physician office record | patient health care services received in a physician office, including admin and clinical data |
| plan | diagnostic, therapeutic and eduational plans to resolve the patient's problems |
| potentially compensable event (PCE) | an accident or medical error that results in personal injury or loss of property |
| preadmission testing (PAT) | incorporates patient registration, testing and other services into one visit prior to inpatient and outpatient surgery; reduces length of stay |
| primary sources | records that document patient care provided by health care professionals |
| problem list | symptoms, specific diagnoses, abnormal findings, physiologic findings in the problem oriented record; continuous, as new findings are added |
| problem oriented medical record (POMR) | now known as FOR |
| problem oriented record (FOR) | systematic method of documentation which consists of four componenets; database, problem list, initial plan and progress notes |
| progress notes | documented as subjective, objective, assessment and plan |
| provisional diagnosis | is obtained from the attending physician and is the diagnosis upon which patient care is based |
| public key | public key cryptography uses algorithm of two keys, one for creating the digital signature and the other to verify a digital signature, and returning the message to it's original form |
| purge record | removing an inactive record from the file system |
| record destruction methods | designated destruction rules for the various types of records, implemented after the end of the record retention period |
| record linkage | same as longitudinal patient record |
| record retention schedule | a set time period for the various types of records |
| reference terminology | a set of concepts and relationships that provide a common reference point for comparisons and aggregation of data about the entire health care process |
| remote storage | storage of records offsite, at another facility |
| report generation | the creation of a healthcare document, consisting of recorded patient information, for analyzing, organizing and presenting for authentication |
| retention period | the length of time a facility will maintain an archived record |
| reverse chronological date order | the most current document is filed first, in the patient record |
| scanner | used to capture paper record images onto the storage media, allowing for rapid automated retrieval of records |
| secondary sources | contain data abstracted from primary sources of patient information |
| sectionalized record | the record is subdivided into sections |
| shadow record | a paper record that contains copies of origianl records and is maintained separately from the primary record |
| signature legend | a document maintianed by the health information department to identify the author by full signature, when initials are used to authenticate entries |
| signature stamp | provider must sign a statement aurthorizing use of this type of signature, in place of actual physician signature |
| SNOMED-CT | Systemized Nomenclature of Medicine, Clinical Terms; controlled clinical reference terminology with comprehensive coverage of diseases, clinical findings, etiologies, procedures, living organisms and outcomes |
| solo practitioner | a physician who practices alone |
| source oriented record (SOR) | the patient record is divided into sections, according to type of treatment; nursing notes are kept in the nursing section, physician orders, progress notes, etc in the medical section, xray results in the radiology section, etc |
| statute of limitations | the time period during which a person may bring forth a lawsuit; when that time period is up, there is no legal right to sue |
| subjective | patient's statement about how they feel, including symptomatic information |
| telephone order | a verbal order taken over the phone by a qualified professional from a physician |
| terminology | a set of terms representing the system of concepts of a particular subject field |
| therapeutic plans | specific medications, goals, procedures, therapies, and treatments used to treat the patient |
| transfer note | documents transfer of a patient to another facility, summarizes reason for admission and transfer, current diagnoses and medical information |
| UMLS | Unified Medical Language System |
| universal chart order | organize reports in the same order for both inpatient and discharged patient records |
| voice order | the physician dictates an order in the presence of a responsible person, no longer accepted as standard practice by health care facilities; voice orders are documented in emergencies only |
Created by:
erosok
Popular Clinical Skills sets