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Chapter 6
| Term | Definition |
|---|---|
| Andressograph machine | |
| Admission note | |
| Admission/discharge record | |
| Admitting disagnosis | |
| Advance directive | |
| Advance directive notification form | |
| AMA- Against medical advice | |
| Alias | |
| Ambulance report | |
| Ambulatory record | |
| Ancillary reports | |
| Ancillary service visit | Anesthesia record |
| Antepartum record | |
| Anto-dumping legislation | |
| APGAR score | |
| Attestation statement | |
| Automatic stop order | |
| Autopsy | |
| Autopsy report | |
| Bedside terminal system | |
| Birth certificate | |
| Birth history | |
| Case management note | |
| Certificate of birth | |
| Certificate of death | |
| CC- Chief complaint | |
| Clinical data | |
| Clinical resume | |
| Comorbidities | |
| Complications | |
| Conditions of admission | |
| Consent to admission | |
| Consultation | |
| Consultation report | |
| Death certificate | |
| Dietary progress note | |
| Discharge order | |
| Discharfe note | |
| Discharge summary | |
| Doctors orders | |
| DRG creep | |
| Durable power of attorney | |
| Emergency record | |
| Encounter | |
| Encounter form | |
| Face sheet | |
| Facility identification | |
| Family history | |
| Fee slip | |
| Final diagnosis | |
| First-listed diagnosis | |
| Follow up progress note | |
| Forms committee | |
| Graphic sheet | |
| Health care proxy | |
| History | |
| HPI- History of present illnesses | |
| Informed consent | |
| Integrated progress notes | |
| Interval history | |
| Labor and delivery record | |
| Licensed practitioner | |
| Macroscopic | |
| Maximizing codes | |
| MAR_ Medication administration record | |
| Necropsy | |
| Necropsy report | |
| Neonatal record | |
| Newborn Id | |
| Newborn physical examination | |
| Newborn progress notes | |
| Non-licensed practioner | |
| Nurses notes | |
| Nursing care plan | |
| Nursing discharge summary | |
| Nursing documentation | |
| Obstetrical record | |
| Occasion of service | |
| Operative record | |
| Outpatient visit | |
| Past history | |
| Pathology report | |
| Patient ID | |
| Patient record documentation committee | |
| Patient property form | |
| Physical examination | |
| Physician office record | |
| Physiciann orders | |
| PACU- Postanesthesia evaluation unit | |
| Postanehesia evaluation note | |
| Postmortem report | |
| Postoperative note | |
| Postpartum record | |
| Preanesthesia evaluation note | |
| Prenatal record | |
| Preoperative note | |
| Principal disgnosis | |
| Principal procedure | |
| Progress notes | |
| RAV- Read and verify | |
| Recovery room record | |
| Rehabilitation therapy progress note | |
| Respiratory therapy progress note | |
| ROS- Review of systems | |
| Routine order | |
| Secondary disgnoses | |
| Secondary procedures | |
| Short stay | |
| Short stay record | |
| Social history | |
| Standing order | |
| Stop order | |
| Superbill | |
| Telephone order call back policy | |
| Tissue report | |
| Transfer order | |
| UACDS- Uniform ambulatory Care data set | |
| UHDDS- uniform hospital discharge data | |
| Upcoding | |
| Verbal order | |
| Written order |
Created by:
s.fitzpatrick410
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