Stack #145923
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| addressograph machine | imprints patient identification information on each report
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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 | face sheet
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| admitting diagnosis | provisional diagnosis, the condition for which the patient is seeking treatment
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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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| 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
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| AMA | against medical advice
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| alias | an assumed named
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| ambulance report | generated by EMTs to document clinical information such as vital signs, level of consciousnes, apperance of the patient, and so on
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| ambulatory record | hospital outpatient records
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| ancillary reports | repotrs documented by lab, radiology, nuclear medicine, and so on
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| ancillary service visit | an appearance to a hospital department to receive an ordered service, test, or procedure
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| anesthesis record | documentation of appropriate monitoring of the patient during administration of anesthesia (AOA)
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| antepartum record | pernatal record, health history of mother, family and social history, pregnancy risk ,performed, meds administered and so on
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| 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
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| APGAR score | measures a baby's appearance, pulse, grimace, activity, and respirations on a scale to 1 to 10
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| attestation statement | signed by attending phys to verify diagnoses and procedures documented and coded at dischare of a hospital patient, discontinued in 1995
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| 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
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| autopsy | an examination of the body after death
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| 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
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| 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
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| 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
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| birth history | documents summary of pregnancy; labor and delivery; newborn's condition at birth
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| case management note | progress notes documented by a case manager. Outlines a discharge plan that includes case management/social services provided and patient education
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| 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
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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; also called death certificate
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| chief complaint (CC) | patient's description of medical condition, stated in the 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 | see discharge summary. Provides info for continuity of care
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| 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
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| 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
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| conditions of admission | see 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 | 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 opinion and findings based on a physical examination and review of patient records
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| death certificate | 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 dietitian or authorized designee. Includes patient's duetary needs and any dietary observations made by 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 | 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
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| doctors orders | aka physician orders
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| DRG creep | 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
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| 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
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| encounter | professional contract 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 | captures charges generated during an office visit and consistss 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. aka admission/discharge record
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| 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
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| 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
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| fee slip | encounter form
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| final diagnosis | diagnosis determined after evaluation and documented by the attending pphysician upon discharge of the patient from the facility
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| follow-up progress note | daily progress notes documneted by the responsible physicians
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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, temp, pulse, respiration, bp, etc using a graph for easy interpretation of data
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| 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
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| history | documents the patient's chief complaint, history of present illness HPI, past/family/social history PFSH, and review of systems ROS
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| 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
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| 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
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| 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
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| 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
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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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| licensed practioner | required to have a public license/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 | see upcoding
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| 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
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| necropsy | see autopsy
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| necropsy report | see autopsy report
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| neonatal record | newborn's record taht contains a birth history, newborn identification, physical examination, and progress notes
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| 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
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| 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
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| 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
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| non-licensed practitioner | does not have license/certification and is supervised by a licensed/certified professional in the delivery of care to patients
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| nurses notes | docs 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 | docs nursing diagnoses as well as interventions used to care for the patient
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| nursing discharge summary | docs patients discharge plands and instructions
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| nursing documentation | cruicial to patient care because the majority of care delivered to inpatients is performed by nursing staff
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| obstertrical record | Mother's record that contains an antepartum record, labor and delivery record, and postpartum record
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| occasion of service | see ancillary service visit
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| 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
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| 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
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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 expelled by the patient; also called tissue report
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| 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
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| patient property form | records items patients bring with them to the hospital
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| patient record committee | see forms committiee
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| physical examinatoin | assessment of the patient's bocy systems to assist in determing a diagnosis, documenting a provisional diagnosis, which may include differential diagnosis
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| 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
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| physician orders | direct the diagnostic and therapeutic patient care activities, also called doctors orders
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| 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
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| postmortem report | see autopsy report
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| postoperative note | progress note documented by the surgeon after the surgery. doc the patient'ss ersponse t surgery and a postoperative diagnosis
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| postpartum record | documents information concerning the mother's condition after delivery
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| preanethesia evaluation note | progress note documented by the anthesiologist prior to the induction of anesthesia
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| prenatal record | see antepartum record
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| preoperative note | progress note documented by the surgeon prior to surgery
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| primary diagnosis | reason the patient sought treatment during that encounter, reflects the current, most significant reason for services provided or procedurs peformed
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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 | 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
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| progress notes | statements related to the course of the patient's illness, response to treatment, and status at discharge
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| provisional autopsy report | conatins cause of death and is to be documented within 72 hours
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| 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
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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 | documented by various rehabilitation therapists taht demonstrate the patient's progress or lack of thereof toward established therapy goals
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| respiratory therapy progress note | documented by respiratory therapists, includes therapy administered, machines used, medications, dates and times, effects of therapy, frequency of therapy
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| 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
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| routine order | physicians orders preapproved by the medical staff, which are preprinted and placed on a patient'srecord
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| secondary diagnoses | additional conditions for which the patient recewived treatment and or impacted the inpatient care
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| secondary proedures | additional procedure(s) performed during inpatient admission
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| short stay | an uncomplicated hospital stay of less than 48 hours
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| 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
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| social history | age-appropriate review of past and current activities such as daily rouotine, dietary habits, exercise routine, marital status, and so on
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| 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
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| 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
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| superbill | see encounter form
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| 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
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| tissue report | see pathology report
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| transfer order | physician order documented to transfer a patient from one facility to another
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| 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
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| upcoding | documentation of diagnoses and procedures tht result in higher payment for a facility; also called maximizing 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 thta are handwritten in a paperbased record or entered into an electronic health record by the responsible physician
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Created by:
dnoplis