The Patient Record
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| abbreviation list |
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| addendum |
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| administrative data | includes demographic, socioeconomic, and financial information
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| age of consent |
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| age of majority |
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| alternate care facilities |
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| alternative storage method |
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| amending the patient record |
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| archived records assessment (A) |
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| ASTM E 1762-Standard Guide for Authentication of Healthcare Information |
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| audit trail |
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| authentication | an entry is signed by the author
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| auto-authentication | Involves a provider authenticating a dictated report prior to its transcription.
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| automated record system |
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| character |
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| chart deficiencies |
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| chronological date order |
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| clinical data | all patient health information obtained throughout the treatment and care of the patient
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| clinical data repository |
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| COmputer STored Ambulatory Record (COSTAR) |
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| countersignature |
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| cryptography |
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| database |
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| deficiency slip |
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| delinquent record |
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| delinquent record rate |
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| demographic data | is patient identification information collected accord¬ing to facility policy and includes the patient's name and other information, such as date of birth, place of birth, mother's maiden name, social security number
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| diagnostic/management plans |
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| digital archive | is a storage solution that consolidates electronic records
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| digital signature |
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| document imaging |
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| electronic health record (EHR) |
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| electronic medical record (EMR) |
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| electronic signature |
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| field |
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| file |
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| hospital ambulatory care record |
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| hospital inpatient record | the care and treatment received by a patient admitted to the hospital
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| hospital outpatient record | documents services re¬ceived by a patient who has not been admitted to the hospital overnight and includes ancillary services (e.g., lab tests, X-rays, and so on), emergency depart¬ment services, and outpatient (or ambulatory) surgery
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| inactive records |
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| incident report |
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| independent database | contains clinical information created by researchers, typically in academic medical centers
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| indexed | which means it is identified according to a unique identification number
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| information capture | the process of recording rep¬resentations of human thought, perceptions, or ac¬tions in documenting patient care, as well as device-generated information that is gathered and/or computed about a patient as part of health care
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| initial plan |
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| integrated record |
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| jukeboxes | store large numbers of optical disks, resulting in huge storage capabilities
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| longitudinal patient record |
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| magnetic degaussing |
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| manual record |
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| mHealth |
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| microfilm |
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| nursing assessment |
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| objective (0) | observations about the patient, such as physical findings or lab or X-ray results
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| off-site storage |
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| optical disk imaging |
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| patient education plans |
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| patient record | is the business record for a patient encounter
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| patient's representative |
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| physician office record |
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| plan (P) | diagnostic, therapeutic, and educational plans to resolve the problems
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| potentially compensable event (PCE) |
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| preadmission testing (PAT) |
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| primary sources |
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| problem list |
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| problem oriented medical record (POMR) |
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| problem oriented record (POR) |
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| provisional diagnosis |
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| public key |
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| purge record | remove inactive records from the file system
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| record destruction methods |
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| record linkage |
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| record retention schedule |
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| remote storage |
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| report generation |
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| retention period |
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| reverse chronological date order |
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| scanner | used to capture paper record images onto the storage media
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| secondary sources |
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| sectionalized record |
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| shadow record | is a paper record that contains copies of original records and is maintained separately from the primary record
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| signature legend |
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| signature stamp |
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| solo practitioner |
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| source oriented record (SOR) |
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| statute of limitations |
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| subjective (S) | patient's statement about how they feel, including symptomatic information
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| telephone order (T.O.) |
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| therapeutic plans |
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| transfer note |
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| voice order (V.O.) |
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Created by:
lisakendall
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