medical records
Quiz yourself by thinking what should be in
each of the black spaces below before clicking
on it to display the answer.
Help!
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| assembly | arranging the documents of the medical records in a specified order after discharge of the patient
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| authorization | a signed consent of the patient or his or her representative to release confidential information
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| compromise care | to make the patient's care less effective
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| contract service | a company hired to perform a function when the health information managenment department is usable to manage the amount of work, such as transripition of dictation
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| discharge summary | a report, dictated by physician at the end of hospitalization, that details the diagnoses and treatment given
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| health information management department | the department, in healthcare facility, responsible for maintaing security and confidentiality of patients records and for promoting responsible use of the records in patients care
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| indexing | assigning a document to the correct patient, document type, and episode of care in an optical imaging system
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| loose documents | documents received by the health information management department, after the patient has been discharged , that must be placed in the records
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| medical transcription | interpretation and typing of reports dictated by physician and other healthcare personnel
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| misflie | to file a record or document in the wrong location
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| operative report | a report dictated by the surgeon detailing the surgical procedure and findings
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| optical imaging system | a computer system in which documents are converted to computer image that can be viewed simultaneously by multiple user
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| quality control | review of documents that have been scanned into an optical imaging system to insure that they are legible and have been indexed correcty
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| scanning | the process of converting a paper document into a computer image
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| medical records | a multiform documents detailing the patients diagnose, diagnostic testing, and treatment given during an encounter with the hospital. portions of the record may be computerized
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Created by:
Smileyjelly
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