Chapter 5
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| patient identification | consists of the patients name and some other peice of identifying information such as medical record number, ssn
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| alias | an assumed name
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| addressograph machine | imprints patient identification information on each report
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| facility identification | includes the name of the facility, mailing address, adn a telephone number
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| face sheet or admission/discharge record | contain patient identification or demographic, financial data, and clinical data information
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| admitting diagnosis or provisional diagnosis | the condition or disease for which the patient is seeking treatment
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| final diagnosis | the diagnosis determined after evaluation and documented by the attenting physician upon discharge of the patient from the facility
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| uniform hospital discharge data set (UHDDS) | the minimum core data set collectec on individual hospital discharges for the medicare and medicaid programs and much of this information is located on the face sheet
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| principal diagnosis | condition established after study te be chiefly responsible for occasioning the admission of the patient to the hospital for care
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| secondary diagnosis | additional conditions for whch the patient received treatment and/or impacted the inpatient care
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| comorbidities | pre-existing/co-existing condition that will, because of its presence with a specific principal diagnosis, cause an increase in the patients length of stay by at least one day in 75% of all cases
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| complications | additional diagnosis that describe conditions arising after the beginning of hospital observation and treatment and that modify the course of the patients illness or the medical care required: they prolong the patients length of stay by at leat one day in
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| principal procedure | procedure performed for definitive or therapuetic reasons, rather than diagnostic, or treat a complication, or that procedure which is most closely related to the pricipal diagnosis
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| secondary procedures | additional procedures performed during inpatient admission
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| attestation statement | verified diagnoses and procedures documented and coded at discharge
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| upcoding or maximizing codes or DRG creep | documentation of diagnoses and procedures that result in higher payment for a facility
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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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| 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
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| informed consent | the process of advising a patient about treatment options and depending on state laws, the provider may be obligated to disclose a patients diagnosis, proposed treatment/surgery, reason for the treatment/surgery, possible complications, likelihood of succ
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| consent to admission or conditions of admission | is a generalized consent that documents a patients consent to receive medical treatment at the facility
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| patient property form | records items patients bring with them to the hospital
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| certificate of birth or birth certificate | is a record of birth information about the newborn patient and the parents and it identifies medical information regarding the pregnancy and birth of the newborn
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| certificate of death or death certificate | contains a record of information regarding the decedent, his or her family, cause of death, adn the disposition of the body
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| emergency record | documents the evaluation adn treatment of patients seen in the facilitys emergency department for immediate attetion of urgent medical conditions or traumatic injuries
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| anti-dumping legislation or (EMTALA) | prevents facilities licensed to provide emergency services from transferring patients who are unable to pay to other institutions adn it requires that a patients condition must be stablilized prior to transfer
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| ambulance report | generated by emergency medical technicians to document clinical information such as vital signs, level of consciousness, appearance of the patient, and so on
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| short stay | an uncomplicated hosptial stay of less than 48 hours
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| discharge summary or clinical resume | provides information for contiunity of care and facilitates medical staff committee review; it can also be used to respond to requests from authorized individuals or agencies
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| history | documents the patients chief complaint, history of present illness, past/family/social history, and review of systems
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| interval history | documents a patients 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 discharge for the same condition
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| physical examination | an assessment of the patients body systens to assist in determining a diagnosis, documenting a provisional diagnosis, and which may also include differential diagnoses
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| differential diagnosis | indicates that several diagnoses are being considered as possible
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| consultation | is the provision of health care services by a consulting physician whose opinion or advice is requested by another physician
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| consultation report | is docmunented by the consultant and includes the consultants opinion adn findings based on a physical examination adn review of patient records
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| physician orders or doctors orders | direct the diagnostic and therapeutic patient care activities
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| progress notes | contain statements related to the coures of the patients illness, response to treatment, and status of discharge
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| integrated progess notes | which means all progress notes documented by physicians, nurses, physical therapists, occupational therapists and other professional staff members are organized in the same section to the record
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| anesthesia record | required when a patient receives 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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| operative record | describes gross findings, organs examined, adn techniques associated wtihe the performance of surgery
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| pathology report or tissue report | assists in the diagnosis and treatment of patients by documenting the analysis of tissue removal surigcally or diagnostically or that expelled by the patient
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| macroscopic | gross examination of tissue; visible to the naked eye
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| recovery room record | delineates are administered to the patient from the time of arrival until the patient is moved to a nursing unit
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| ancillary reports | documented by such departments as laboratory, radiology, nuclear medicine, and so on; they assist physicians in diagnosis and treatment of patients
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| nursing documentation | plays a crucial role in patient care because teh majority of care delivered to inpatients is performed by nursing staff, which includes RN, LPN, and CNA
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| obstetrical record | the mothers record and contains sn antepartum report, labor and delivery record, and postpartum record
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| neonatal record | is the newborns record and contains a birth history, newborn identification, phyical examination, and progress notes
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| antepartum record or prenatal record | started in the physicians office and includes health history of the mother, family, and social history, pregnancy risk factors, care during pregnancy includes tests performed, medications administered
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| labor and delivery record | records progress of the mother from time of admission through time of delivery
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| postpartum record | documents information concerning the mothers condition after delivery
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| birth history | documents summary of pregnancy,labor and delivery, and newborns condition at birth
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| newborn identification | immediatley following birth, footprints and fingerprints of the newborn are created and a writst or ankle band is placed on the newborn; within 12 hours of birth an identification form is also used to document information aout the newborn and mother
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| newborn physical examination | an assessment of the newborns condition immediatley after birth, including time and date of birth, vital signs, birth weight and length, head and chest measurements, general appearance, and phyisical findings is completed
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| newborn progress nots | documents information gathered by nurses in the nursury and includes vital signs, skin color, intake and output,weight, medications and treatments and observations
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| APGAR score | measures the babys appearance A-skin color, P-grimace G-irritablility A-muscle tone and motion R-respirations on a scale of 1-10 with up to two points assigned for each measurement adn 10 being the max score
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| autopsy or necropsy | ia an examination of a body after death that includes the macroscopic examination of vital organs adn tissue specimens to assist in determining a cause of death adn the character or extent of changes produced by disease
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| provisional autopsy report | contains a cause of death, is to be documented within 72 hours
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| autopsy report or necropsy report or postmortem report | may take up to 60 days, and contains summary of patients clinical history including diseases, surgical history, and treatment; detailed results of the macroscopic and microscopic findings including external appearance of the body and internal examination
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| ambulatory records or hospital outpatient records | include a patient registration form similar to the inpatient face sheet, and depending on the complexity of the outpatient services provided, additional reports include ancillary reports, progress notes, physician orders, operative reports, pathology repo
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| short stay record | allows providers to record the history, phyicial examination, progress notes, physician orders, and nursing documentation on one double sided form
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| uniform ambulatory care data set (UACDS) | is the minimum core data set collected on medicare and medicaid outpatients
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| outpatient visit | is the visit of a patient on one calendar day to one or more hospital departments for the purpose of receiving outpatient health care services
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| encouter | a professional contact between a patient and a provider who delivers services or is professionaly responsible for services delivered to a patient
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| ancillary service visit or occasion of service | is the appearance of an outpatient to a hospital department to receive an ordered service, test, or procedure
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| licensed practioner | is requiered to have a public license/certification to deliver care to patietns, and a practioner can also be a provider
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| non-licensed practioner | does not have a public license/certificate and is supervised by a licensed/cerified professional in the delivery of care to patients
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| primary diagnosis | reason the patient sought out treatment during that encoutner
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| physician office records | should contain patient registration information, a problem list, a medication record, progress notes and results of the ancillary reports
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| encouter form or superbill or free slip | 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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| forms committee or patient record committee | established to oversee this process and to approve forms used in the record
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| health care proxy or 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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| chief complaint | patients description of medical condition stated in the patients own words
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| history of present illness | chronological description of patients present condtion from time of onset to present HPI should include location, quality, severity, duration of the condition, and associated signs and symptoms
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| past history | summary of past illness, operations, injuries, treatments, and known allergies
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| family history | a review of the medical events in the patients family including diseases that may be hereditary or present a risk to the patient
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| social history | an 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
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| medications | a listing of current medications and dosages
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| review of systems | inventory by systems to document subjective symptoms stated by the patient. Provides an opportunity to gather information that the patient may have forgotten to mention or that may seem unimportant
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| discharge order | the final physician order documented to release a patient from a facility
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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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| routine order | physician orders preapproved by the medical staff, which are preprinted and placed on a patients record
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| standing order | physician orders preapproved by the medical staff that direct the continual administration of specific activities for a specific period of time as a part of the diagnostic or therapeutic care
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| stop order or automatic 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 order
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| telephone order | a verbal order dictated via telephone to an authorized facility staff member
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| telephone order call back policy | requires the authorized staff member to read back and verify what the physician dictatedto ensure that the order is entered accurately
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| RAV (read and verified) | abbreviation entered by the staff member who documents a telephone order to document that the telephone order call back policy was followed
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| transfer order | a physician order documented to transfer a patient from one facitliy to another
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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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| voice order | a verbal order dictated to an authorized facility staff member by the responsible physician who also happens to be present
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| written order | orders that are handwritten in a paper-based record or entered into an electronic health record by the responsible physician
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| admission note | progress note documented by the attending physicisn at the time of patient admission. Includes reason for admission including description of patients condition, brief history of present illness, patient care plan, method/mode of arrival, patients respons
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| follow up progress note | daily progress notes documented by the responsible physicians. Includes patients condition, findings on examination, significant changes in condition and/or diagnosis, response to medications administered, response to clinical treatment, abnormal test fin
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| discharge note | final progress note documented by the attending physician. Includes patients discharge destination, discharge medications, activity level allowed, and follow up plan
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| case management note | progress note documented by a case manager. Outlilnes a discharge plan that includes case management/social services provided and patient education
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| dietary progress note | progress note documented by the dietician. Includes patients dietary needs and any dietary observations made by staff
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| rehabilitation theraphty progress note | progress notes documented by various rehabilitation therapists that demonstrate the patients progress toward established therapy goals
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| respiratory theraphy progress note | progress notes documented by respiratory therapists. Include therapy administration, machines used, medications added to machines, type of therapy, dates/time of administration, specifications of the prescription, effects of therapy including any adverse
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| preanesthesia evaluation note | progress notes documented by the anesthesiologist prior to the induction of anesthesia. Includes evidence of patient interview to verify past and present medical and drug history and previous anesthesia experience, evaluation of the patients physical sta
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| postanesthesia note | progress notes documented by the anesthesiologist. Includes patients general condition following surgery, description of presence or absence of anesthesia related complications and/or postoperative abnormalities, blood pressure, pusle, presence/absence o
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| preoperative note | progress notes documented by the surgeon prior to surgery. summarizes the patients condition and documents a preoperative diagnosis
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| postoperavtive note | protress note documented by the surgeon after surgery. documents the patients response to surgery and postoperative diagnosis
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| nursing care plan | documents nursing interventions to be used to care for the patient
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| nurses notes | documetns daily observation about patients including initial history of the patient, reaction to treatments, and treatmetns rendered
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| nursing discharge summary | documents patients discharge plans and instructions
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| graphic sheet | documents patients vital signs using a graph for easy interpretation of data
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| medication administration record (MAR) | documents medications administered, date and time of administration, name of drug, dosage, route of administration, and initials of nurse administering the medication
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| bedside terminal system | computer system located at the patients bedside, which is used to automate nursing documentation. Patient information can be entered, stored, and retrieved adn displayed
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Or sort by any of the columns using the down arrow next to any column heading.
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