Chapter 5
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| addressograph machine | plastic card containing patient identification; used to imprint information on each report in the patient record
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| admission note | progress note documented by the attending physician at the time of patient admission
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| admission/discharge record | aka face sheet;contains patient identification, financial, and clinical information
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| admitting diagnosis | aka provisional diagnosis;working, tentative, admission, and preliminary diagnosis obtained from the attending physician
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| advance directive | legal document that provides instructions as to how patients want to be treated in the event they become very ill and there is no reasonable hope for recovery
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| advance directive notification form | signed by the patient as proof they were notified of their right to have an advance directive
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| against medical advice(AMA) | patients who sign themselves out of a facility and sign a release from responsibility for discharge
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| alias | an assumed name
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| ambulance report | generated by emergency medical technicians to document clinical information such as vital sign, level of consciousness, appearance of the patient, and so on
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| ambulatory record | aka hospital out patient record; documents services recieved by a patient who has not been admitted to the hospital overnight, and includes ancillary services, emergency department services, and outpatient surgery
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| ancillary reports | documented by such departments as laboratory, radiology, nuclear medicine to assist physicians in diagnosis and treatment of patients
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| ancillary service visit | appearance of an outpatient to a hospital department to recieve an ordered service, test, or procedure. aka occasion of service
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| anesthesia record | required when a patient recieves an anesthetic other than a local anesthetic to document patient monitoring during administration of anesthetic agents and other activities related to the surgical episode
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| antepartum record | generated in the physician office and includes health history of the mother, family and social history, pregnancy risk factors, care during pregnancy including tests performed and medications administered. aka prenatal record
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| anti-dumping legislation | aka emergency medical treatment and labor act (EMTALA); addressed the problem of hospitals failing to screen, treat, or appropriatley transfer patients by establishing criteria for the discharge and transfer of Medicare and Medicaid patients
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| APGAR score | Measures a baby's appearance, pulse, grimace, activity, and respirations on a scale of 1 to 10
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| attestation statement | signed by the attending physician to verify diagnosis and procedures documented and coded at discharge of a hospital patient
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| automatic stop order | aka stop order; as a patient safety mechanism, state law mandates, and in the absence of state law facilities decide, for which circumstances preapproved standing physician orders are automatically discontinued, requiring the physician to document a new o
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| autopsy | an examination of a body after death
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| autopsy report | to be documented within 60 days and contains summary of patient's clinical history including diseases, surgical history, and treatment
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| bedside terminal system | computer system located at the patient's bedside
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| birth certificate | aka certificate of birth; record of birth informatin about the newborn patient and the parents, and identifies medical information regarding the pregnancy and birth of the newborn
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| birth history | documents summary of the pregnancy, labor, and delivery, and newborn's condition at birth.
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| case management note | progress note documented by a case manager
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| certificate of birth | aka birth certificate; record of birth informatin about the newborn patient and the parents, and identifies medical information regarding the pregnancy and birth of the newborn
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| certificate of death | contains a record of information regarding the decedent, his or her family, cause of death, and the disposition of the body
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| chief complaint(CC) | patient's description of medical condition, stated in patient's own words
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| clinical data | health information obtained throughout treatment and care of patient
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| clinical resume | aka discharge summary; provides information for continuity of care and facilitates medical staff committee review; documents patient's hospitialization, including reasons for hospitalization, course of treatment, and condition at discharge
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| comorbidities | pre-existing condition that will, because of its 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
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| complications | additional diagnosis that describe conditions arising after the beginning of hospital observation and treatment and the modify the course of the patient's illness or the medical care required
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| conditions of admission | aka consent to admission; a generalized consent that documents a patient's consent to receive medical treatment at the facility
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| consent to admission | aka conditions of admission; a generalized consent that documents a patient's consent to receive medical treatment at the facility
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| consultation | provision of health care services by a consulting physician whose opinion or advice is requested by another physician
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| consultation report | documented by the consultant and includes the consultant's opinions and findings based on a physical examination and review of patient records
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| death certificate | aka certificate of death; contains a record of information regarding the decedent, his or her family, cause of death, and the disposition of the body
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| dietary progress note | progress note documented by the dietition; includes patient's dietary needs and any dietary observations made by the staff
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| differential diagnosis | indicates that several diagnoses are being considered as possible
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| discharge note | final progress note documented by the attending physician; includes patient's discharge destination, discharge medications, activity level allowed, and follow-up plan
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| discharge order | final physician order documented to release a patient from a facility
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| discharge summary | aka clinical resume; provides information for continuity of care and facilitates medical staff committee review; documents patient's hospitialization, including reasons for hospitalization, course of treatment, and condition at discharge
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| doctors orders | aka physician orders; direct the diagnostic and therapeutic patient care activities
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| DRG creep | aka upcoding; documentation of diagnoses and procedures that result in higher payment for a facility
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| durable power of attorney | aka health care proxy; legal document in which the patient chooses another person to make treatment decisions in the event the patient becomes incapable of making these decisions
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| emergency record | documents the evaluation and treatment of patients seen in the facility's emergency department for immediate attention of urgent medical conditions or traumatic injuries
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| encounter | professional contact between a patient and a provider who delivers services or is professionally responsible for services delivered to a patient
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| encounter form | commonly used in physician offices to capture charges generated during an office visit and consists of a single page that contains a list of common services provided in the office
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| face sheet | contains patient identification, financial and clinical information
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| facility identification | name of the facility, mailing address, and a telephone number; included on each report in the record so that the individual or health care facility in receipt of copies of the record can contact the facility for clarification of record content
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| family history | rteview of the medical event s in the patient's family, including disease which may be hereditary or present a risk to the patient
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| fee slip | aka encounter form; commonly used in physician offices to capture charges generated during an office visit and consists of a single page that contains a list of common services provided in the office
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| final diagnosis | diagnosis determined after evaluation and documented by the attending physician upon discharge of the patient from the facility
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| follow-up progress note | daily progress note, documented by the responsible physicians. include patient's condition, findings on examination, significant changes in condition and/or diagnosis, response to medications administerd, response to clinical treatment, abnormal test find
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| forms committee | established to oversee the process of adding, deleting, and changing forms and to approve forms used in the record
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| graphic sheet | documents patient's vital signs using a graph for easy interpretation of data
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| health care proxy | aka durable power of attorney; legal document in which the patient chooses another person to make treatment decisions in the event the patient becomes incapable of making these decisions
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| history | documents the patient's chief complaint, history of present illness, past/family/social histpry, and review of systems
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| history of patient illness(HPI) | chronological description of patients present condition from time of onset to present
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| informed consent | process of advising a patient about treatment options and, depending on state laws, the provider may be obligated to disclose a patient's diagnosis proposed treatment/surgery reason for the treatment/surgery, possible complications, likelihood of success,
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| integrated progress notes | progress notes documented by physicians, nurses, physical therapists, occupational therapists, and other professional staff members are organized in the same section of the record
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| interval history | documents a patient's history of present illness and any pertinent changes and physical findings that occured since a previous inpatient admission if the patient is readmitted within 30 days after discharge of the same condition
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| labor and delivery record | records progress of the mother from time of admission through time of dilevery
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| licensed practitioner | required to have a public licens/certification to deliver care to patients
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| macroscopic | gross examination of tissue, visible to the naked eye
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| maximizing codes | aka upcoding; documentation of diagnoses and procedures that result in higher payment for a facility
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| medication administration record (MAR) | documents medications administered, date and time of administration, name of drug, doasage, route of administration, and initials of nurse administering medication
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| necropsy | aka autopsy;an examination of a body after death
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| necropsy report | aka autopsy report; to be documented within 60 days and contains summary of patient's clinical history
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| neonatal record | newborns record that contains a birth history, newborn identification, physical examination, and progress notes
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| newborn identification | immediately following birth, footprinits and fingerprints of the newborn are created, and a wrist or ankle band is placed on the newborn
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| newborn physical examination | an assessment of the newborn's condition immediately after birth, including time and date of birth, vital signs, birth weight and length, head and chest measurements, general appearance and physical findings
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| newborn progress notes | documents information gathered by nurses in the nursery and inlcudes vital signs, skin color, intake and output, weight, medications and treatments,and observations
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| non-licensed practitioner | does not have a public license/certification and is supervised by a licensed/certified professional in the delivery of care to patients
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| nurses notes | documents daily observation about patients, including an initial history of the patient, patient's reactions to treatments and treatments rendered
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| nursing care plan | documents nursing diagnoses as well as interventions used to care for the patient
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| nursing discharge summary | documents patient discharge plans and instructions
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| nursing documentation | crucial to patient care because the majority of care delivered to inpatients is performed by nursing staff
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| obstetrical record | mother's record that contains an antepartum record, labor and delivery record, and postpartum record
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| occasion of service | aka ancillary service visit; appearance of an outpatient to a hospital department to recieve an ordered service, test, or procedure. aka occasion of service
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| operative record | describes gross findings, organs examined, and techniques associated with the performance of surgery
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| past history | summary of past illnesses, operations, injuries, treatments, and known allergies
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| pathology report | assists in the diagnosis and treatment of patients by documenting the analysis of tissue removed surgically or diagnostically, or that the patient expelled
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| patient identification | patient's name and some other piece of identifying information such as medical record number, date of birth, or social security number
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| patient property form | records items patients bring with them to the hospital
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| patient record committee | aka forms committee; established to oversee the process of adding, deleting, and changing forms and to approve forms used in the record
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| phsyical examination | assessment of the patient's body systems to assist in determining a diagnosis, documenting a provisional diagnosis, which may include differential diagnoses
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| physician office record | documents patient health care services recieved in a physican's office
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| physician orders | direct the diagnostic and therapeutic patient care activities; aka doctors orders
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| postanesthesia note | progress note documented by the anesthesiologist; includes patient's general condition following surgery, description of presence/absence of anesthesia-related complications and/or postoperative abnormalities, blood pressure, pulse, presence/absence of sw
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| postmortem note | aka autopsy report; to be documented within 60 days and contains summary of patient's clinical history including diseases, surgical history, and treatment
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| postoperative note | progress note documented by the surgeon after surgery; documents the patient's response to surgery and a postoperative diagnosis
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| postpartum record | documents information concerning the mother's condition after delivery
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| preanesthesia evaluation note | Progress note documented by the anesthesiologist prior to the induction of anesthesia.
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| prenatal record | aka antepartum record; generated in the physician office and includes health history of the mother, family and social history, pregnancy risk factors, care during pregnancy including tests performed and medications administered.
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| preoperatiive note | progress note documented by the surgeon prior to surgery
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| primary diagnosis | reason the patient sought treatment during that encounter
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| outpatient visit | visit of a patient on one calender day to one or more hospital departments for the purpose of receiving outpatient health care services
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| principal diagnosis | condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care
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| principal procedure | procedure 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
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| progress notes | contain statements related to the course of the patient's illness, response to treatment and status at discharge
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| provisional autopsy report | contains a cause of death and is to be documented within 72 hours
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| read and varified (RAV) | abbreviation entered by staff memeber who documents a telephone order to document that the telephone order call-back policy was followed.
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| recovery room record | delineates care administered to the patient from the time of arrival until the patient is moved to a nursing unit
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| rehabilitation therapy progress note | progress notes documented by various rehabilitation therapists that demonstrate the patient's progress toward established therapy goals
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| respiratory therapy progress note | progress notes documented by respiratory therapists; include therapy administered, machines used, mecications added to machines, type of therapy, dates/times of administration, specifications of the perscription, effects of therapy including any adverse r
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| review of systems (ROS) | inventory by systemsto reveal subjective symptoms stated by the patient
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| routine order | physican orders preapproved by the medical staff, which are preprinted and placed on a patient's record
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| secondary diagnoses | additional conditions for which the patient recwived treatment and/or impacted the inpatient care
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| secondary procedures | additional procedures performed during inpatient admission
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| short stay | an uncomplicated hospital stay of less thatn 48 hours
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| short stay record | allows providers to record the patient's history, physical examination, progress notes, physician orders, and nursing documentation on one double-sided form
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| social history | age-appropriate review of past and current activities such as daily routine, dietary habits, exercise routine,marital status, occupation, sleeping patterns, smoking, use of alcohol and other drugs, sexual activities, and so on
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| standing order | physican orders preapproved by the medical staff that direct the continual administration og specific activities for a specific period of time as part of diagnostic or therapeutic care
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| stop order | as a patient safety mechanism, state law mandates, and in the absense of state law facilities decide, for which circumstances preapproved standing physican orders are automatically discontinued, requiring the physican to document a new order.
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| superbill | aka encounter form; commonly used in physician offices to capture charges generated during an office visit and consists of a single page that contains a list of common services provided in the office
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| telephone order call back policy | requires the authorized staff member to read back and verify what the physician dictated to ensure that the order is entered accuratley
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| tissue report | aka pathology report; assists in the diagnosis and treatment of patients by documenting the analysis of tissue removed surgically or diagnostically, or that the patient expelled
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| transfer order | physican order documented to transfer a patient from one facility to another
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| Uniform Ambulatory Care Data Set (UACDS) | minimum core data set collected on Medicare and Medicaid outpatients
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| Uniform Hospital Discharge data set (UHDDS) | minimum core data set collected on individuals hospital discharges for the Medicare and Medicaid programs
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| upcoding | documentation of diagnoses and procedures that result in higher payment for a facility; aka minimizing codes or DRG creep
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| verbal order | orders dictated to an authorized facility staff member because the responsible physician is unable to personally document the order
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| written order | orders that are handwritten in a paper based record or entered into a electronic healtht record by the responsible physician
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