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
Stack #145923
| Question | Answer |
|---|---|
| addressograph machine | imprints patient identification information on each report |
| admission note | progress note documented by the attending physician at the time of patient admission |
| admission/discharge record | face sheet |
| admitting diagnosis | provisional diagnosis, the condition for which the patient is seeking treatment |
| advance directive | a legal document in which patients provide instructions as to how they want to be treated in the event they become very ill and there is no reasonable hope for recovery |
| advance directive notification form | a form signed by the patient to document that they have been notified of their right to have an advance directive |
| AMA | against medical advice |
| alias | an assumed named |
| ambulance report | generated by EMTs to document clinical information such as vital signs, level of consciousnes, apperance of the patient, and so on |
| ambulatory record | hospital outpatient records |
| ancillary reports | repotrs documented by lab, radiology, nuclear medicine, and so on |
| ancillary service visit | an appearance to a hospital department to receive an ordered service, test, or procedure |
| anesthesis record | documentation of appropriate monitoring of the patient during administration of anesthesia (AOA) |
| antepartum record | pernatal record, health history of mother, family and social history, pregnancy risk ,performed, meds administered and so on |
| anti-dumping legislation | Emergency Medical Treatment and Labor Act EMLTA,addresses the problem of hospitals failing to screen, treat, or appropriately transfer patients for discharge or transfer of Medicare and Medicaid patients |
| APGAR score | measures a baby's appearance, pulse, grimace, activity, and respirations on a scale to 1 to 10 |
| attestation statement | signed by attending phys to verify diagnoses and procedures documented and coded at dischare of a hospital patient, discontinued in 1995 |
| automatic stop order | patient safety, state law mandates/decides for which circumstances preapproved standing phys orders are automatacally stopped, requiring the phys to document a new order |
| autopsy | an examination of the body after death |
| autopsy report | documented in 60 days, contains summary of patient's clinical history, surgical history, and treatment; results of macroscopic/microscopic findings; contributing factors that led to death; and authentication by pathologist |
| bedside terminal system | computer system located at the patient's bedside. Used to automate nursing documentation; patient information can be entered, stored, retrieved, and displayed |
| birth certificate | record of birth information about the newborn patient and the parents, and indentifies medical info regarding the pregnancy and birth of the newborn |
| birth history | documents summary of pregnancy; labor and delivery; newborn's condition at birth |
| case management note | progress notes documented by a case manager. Outlines a discharge plan that includes case management/social services provided and patient education |
| certificate of birth | record of birth information about the newborn patient and the parents, and indentifies medical info regarding the pregnancy and birth of the newborn |
| certificate of death | contains a record of information regarding the decedent, his or her family, cause of death, and the disposition of the body; also called death certificate |
| chief complaint (CC) | patient's description of medical condition, stated in the patient's own words |
| clinical data | health information obtained throughout treatment and care of patient |
| clinical resume | see discharge summary. Provides info for continuity of care |
| comorbidities | pre-existing condition that will, because ofits presence with a specific principal diagnosis, cause an increase in the patient's length of stay by at least one day in 75% of the cases |
| complications | additional diagnoses that describe conditons arising after the beginning of hospital treatment; they prolong the patient's stay by at least one day 75% of the cases |
| conditions of admission | see consent to admission. A generalized consent that documents a patient's consent to receive medical treatment at the facility |
| consent to admission | A generalized consent that documents a patient's consent to receive medical treatment at the facility |
| consultation | provision of health care services by a consulting physician whose opinion or advice is requested by another physician |
| consultation report | documented by the consultant and includes the consultant's opinion and findings based on a physical examination and review of patient records |
| death certificate | contains a record of information regarding the decedent, his or her family, cause of death, and the disposition of the body |
| dietary progress note | progress note documented by the dietitian or authorized designee. Includes patient's duetary needs and any dietary observations made by staff |
| differential diagnosis | indicates that several diagnoses are being considered as possible |
| discharge note | final progress note documented by the attending physician. Includes patient's discharge destination, discharge medications, activity level allowed, and follow-up plan |
| discharge order | final physician order documented to release a patient from a facility |
| discharge summary | provides information for continuity of care and facilitates medical staff committee review; documents the patient's hospitalization, including reason(s) for hospitalization, course of treatment, and condition at time of discharge; aka clinical resume |
| doctors orders | aka physician orders |
| DRG creep | upcoding, documentation of diagnoses and procedures that result in higher payment for a facility |
| durable power of attorney | aka health care proxy |
| emergency record | documents that evaluation and treatment of patients seen in the facility's emergency department for immediate attention or urgent medical conditions or traumatic injuries |
| encounter | professional contract between a patient and a provider who delivers services or is professionally responsible for services delivered to a patient |
| encounter form | captures charges generated during an office visit and consistss of a single page that contains a list of common services provided in the office |
| face sheet | contains patient identification, financial, and clinical information. aka admission/discharge record |
| facility identification | name, mailing address, and telephone number; included on each report in the record so that an individual or health care facility in receipt of copies can contact the facility for clarification or record content |
| family history | review of the medical events in the patient's family, including diseases which may be hereditary or present a risk to the patient |
| fee slip | encounter form |
| final diagnosis | diagnosis determined after evaluation and documented by the attending pphysician upon discharge of the patient from the facility |
| follow-up progress note | daily progress notes documneted by the responsible physicians |
| forms committee | established to oversee the process of adding, deleting, and changing forms and to approve forms used in the record |
| graphic sheet | documents patient's vital signs, temp, pulse, respiration, bp, etc using a graph for easy interpretation of data |
| health care proxy | legal document (NYS) in which the patient chooses another person to make treatment decisions in the event the patient becomes incapable of making these decisions |
| history | documents the patient's chief complaint, history of present illness HPI, past/family/social history PFSH, and review of systems ROS |
| history of present illness (HPI) | chronological description of patient's present condition from the time of onset to present; should include location, quality, severity, duration of the condition, and associated signs and symptoms |
| informed consent | process of advising a patient about treatment optionsand, depending on state laws, the provider may be obligated to disclose a patinet's diagnosis, proposed treatment/ssurgery, reason for the treatment/surgery, possible complicaiton, likelihood of success |
| intergrated progress notes | P notes documented by physicians, nurses, physical therapists, occ therapists, and other professional staff members are organized in the same section of the record |
| interval history | documents a patient's history of present illness and any pertinent changes and physical findings that occurred since a previous inpatient admission if the patient is readmitted within 30 days after dischare for the same condition |
| labor and delivery record | records progress of the mother from time of admission through time of delivery |
| licensed practioner | required to have a public license/certification to deliver care to patients |
| macroscopic | gross examination of tissue; visible to the naked eye |
| maximizing codes | see upcoding |
| medication administration record (MAR) | documents medications administered, date and time of administration, name and drug, dosage, route of administration, and initials of nurse administering medication |
| necropsy | see autopsy |
| necropsy report | see autopsy report |
| neonatal record | newborn's record taht contains a birth history, newborn identification, physical examination, and progress notes |
| newborn identification | following birth, footprints and fingerprints fo the newborn are created, and a wrist or ankle band is placed on the newborn (with identical band placed on the mother) within 12 hours of birth an identification form isalso used to document information abou |
| newborn physical examination | assessment of the newborn's condition immediately after birth, time and date of birth, vital signs, birth weight and length, head and chest measurements, general appearance and physical findings |
| newborn progress notes | info gathered by nurses in teh nursery and includes vital signs, skin color, intake and output, weight, medications and treatments, and observations |
| non-licensed practitioner | does not have license/certification and is supervised by a licensed/certified professional in the delivery of care to patients |
| nurses notes | docs daily observation about patients, including an initial history of the patient, patient's reactions to treatments, and treatments rendered |
| nursing care plan | docs nursing diagnoses as well as interventions used to care for the patient |
| nursing discharge summary | docs patients discharge plands and instructions |
| nursing documentation | cruicial to patient care because the majority of care delivered to inpatients is performed by nursing staff |
| obstertrical record | Mother's record that contains an antepartum record, labor and delivery record, and postpartum record |
| occasion of service | see ancillary service visit |
| operative record | describes gross findings, and techniques associated with the performance of surgery. to be dictated/hand written immediately following the operation and authenticated by the responsible surgeon |
| outpatient visit | visit of a patient on one calendar day to one or more hospital departments for the purpose of receiving outpatient helath care services |
| past history | summary of past illnesses, operations, injuries, treatments, and known allergies |
| pathology report | assists in the diagnosis and treatment of patients by documenting the analysis of tissue removed surgically or diagnostically, or that expelled by the patient; also called tissue report |
| patient identification | name and other piece of identifying info such as medical record number, date of birth, or ss number; must be included on every page/screen/automated report |
| patient property form | records items patients bring with them to the hospital |
| patient record committee | see forms committiee |
| physical examinatoin | assessment of the patient's bocy systems to assist in determing a diagnosis, documenting a provisional diagnosis, which may include differential diagnosis |
| physician office record | documets patient helath care sevices received in a physician's office. conntains patient registration number, problem list,medication record, progress notes,and results of ancillary reports |
| physician orders | direct the diagnostic and therapeutic patient care activities, also called doctors orders |
| postanesthesia note | progress note doc by the anesthesiologist. includes patient's general condition following surgery, description of presence/absence of anthesia-related complications and/or postoperative abnormalities, blood pressure, pulse, presence/absence of swallowing |
| postmortem report | see autopsy report |
| postoperative note | progress note documented by the surgeon after the surgery. doc the patient'ss ersponse t surgery and a postoperative diagnosis |
| postpartum record | documents information concerning the mother's condition after delivery |
| preanethesia evaluation note | progress note documented by the anthesiologist prior to the induction of anesthesia |
| prenatal record | see antepartum record |
| preoperative note | progress note documented by the surgeon prior to surgery |
| primary diagnosis | reason the patient sought treatment during that encounter, reflects the current, most significant reason for services provided or procedurs peformed |
| principal diagnosis | condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care |
| principal procedure | perfomed for definitive or therapeutic reasons, rather than diagnostic purposes, or to treat a complication, or that procedure which is most closely related to the principal diagnosis |
| progress notes | statements related to the course of the patient's illness, response to treatment, and status at discharge |
| provisional autopsy report | conatins cause of death and is to be documented within 72 hours |
| read and verify (RAV) | abbreviation entered by staff member who documents a telephone order to document that the telephone order call-back policy was followed |
| recovery room record | delineates care administered to the patient from the time of arrival until the patient is moved to a nursing unit |
| rehabilitation therapy progress note | documented by various rehabilitation therapists taht demonstrate the patient's progress or lack of thereof toward established therapy goals |
| respiratory therapy progress note | documented by respiratory therapists, includes therapy administered, machines used, medications, dates and times, effects of therapy, frequency of therapy |
| review of systems (ROS) | inventory by systems to reveal subjective symptons stated by the patient; provides an opportunity to gather information that the patient may have forgotten to mention or that may have seemed unimportant |
| routine order | physicians orders preapproved by the medical staff, which are preprinted and placed on a patient'srecord |
| secondary diagnoses | additional conditions for which the patient recewived treatment and or impacted the inpatient care |
| secondary proedures | additional procedure(s) performed during inpatient admission |
| short stay | an uncomplicated hospital stay of less than 48 hours |
| short stay record | allows providers to record the patient's history, physical exam, progress notes, phy orders, and nursing documentation on one double-sided form |
| social history | age-appropriate review of past and current activities such as daily rouotine, dietary habits, exercise routine, marital status, and so on |
| standing order | phy orders preapproved by the medical staff taht direct the continual adminstration of specific activities for a speciific period of time as part of diagnostic care |
| stop order | as a patient safety mechanism, state law mandates, and in the absence of state law facilities decide, for which circumstances preapproved standing phy orders are stopped, requiring the phy to document a new order |
| superbill | see encounter form |
| telephone order call back policy | requires the authorized staff member to read back and veriify what the phy dictated to ensure that the order is entered accurately |
| tissue report | see pathology report |
| transfer order | physician order documented to transfer a patient from one facility to another |
| Uniform Hospital Care Data Set (UHDDS) | minimum core data set collected on individual hospital discharges for the Medicare and Medicaid programs; much of this information is located on the face sheet |
| upcoding | documentation of diagnoses and procedures tht result in higher payment for a facility; also called maximizing codes or DRG creep |
| verbal order | orders dictated to an authorized facility staff member because the responsible physician is unable to personally document the order |
| written order | orders thta are handwritten in a paperbased record or entered into an electronic health record by the responsible physician |
Created by:
dnoplis