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HIT 110 Chapter 3

Content and Structure of the Health Record

TermDefinition
Accreditation process in which a health care organization undergoes an examination of its systems, processes, and performance to make sure that it is conducting business in a manner that meets predetermined criteria and is consistent with national standards.
The Accreditation Association for Ambulatory Health Care (AAAHC) is a private, non-profit organization formed in 1979 that developes standards to advance and promote patient safety, quality care, and value for ambulatory health care through peer-based accreditation processes, education, and research.
Accreditation Commission for Health Care (ACHC) a US non-profit health care accrediting organization that was established in 1985 by home care health providers to create an accreditation option which was more focused on the needs of small providers
Advance Directive A legal written document that describes the patient's preferences regarding future healthcare or stipulates the person who is authorized to make medical decisions in the even the patient is incapable of communicating
American Accreditation Healthcare Commission (URAC) An organization that focuses on implementing and maintaining accreditation standards for managed care facilities
American Association for Accreditation of Ambulatory Surgery Facilities (AAAASF) established in 1980 to develop an accreditation program to standardize and improve the quality of medical and surgical care in ambulatory surgery facilities.
American Correctional Association An organization that developed basic accreditation standards for healthcare in correctional facilities
American Osteopathic Association (AQA) The professional association of osteopathic physicians, surgeons, and graduates of approved colleges of osteopathic medicine that inspects and accredits osteopathic colleges and hospitals
Care Plan The specific goals in the treatment of an individual patient, amended as the patient's condition requires, and the assessment of the outcomes of care; serves as the primary source for ongoing documentation of the resident's care, condition, and needs.
Certification The process by which a duly authorized body evaluates and recognizes an individual, institution, or education program as meeting predetermined requirements.
Commission on Accreditation of Rehabilitation Facilities (CARF) is an international, non-profit organization founded in 1966 that provides accreditation standards and surveyors for organizations working in the human services field worldwide.
Community Health Accreditation Program A group that surveys and accredits both home healthcare and hospice organizations
Computer-based Patient Record (CPR) Electronic patient record housed in a system designed to provide users with access to complete and accurate data, practitioner alerts and reminders, clinical decision support systems, and links to medical knowledge
Conditions for Coverage Obtaining Medicare certification for an ASC involves the following four steps: Obtaining a National Provider Identifier, Enrolling in Medicare, Complying with Medicare’s Conditions for Coverage (CFCs) & Compliance Survey
Conditions for Participation The administrative and operational guidelines and regulations under which facilities are allowed to take part in the Medicare and Medicaid programs; published by CMS
Deemed Status In order for a healthcare organization to participate in and receive payment from the Medicare or Medicaid programs, it must be certified as complying with the Conditions of Participation (CoP), or standards, set forth in federal regulations
Expressed Consent To convey in writing, by gesture, or verbally the agreement or permission of a patient to receive treatment
Imaging Technology Computer software designed to combine health record text files with diagnostic imaging files
Implied Consent the granting of permission for health care without a formal agreement between the patient and health care provider.
Joint Commission A private, not for profit organization that evaluates and accredits hospitals and other healthcare organizations on the basis of predefined performance standards
Licensure the granting of permission by a competent authority (usually a government agency) to an organization or individual to engage in a practice or activity that would otherwise be illegal
Medical Staff Privileges Permission granted to provide clinical services in a heathcare facility based on the credentials of the individual and limited to a specific scope of practice
Medicare Conditions of Participation or Conditions for Coverage A publication that describes the requirements that institutional providers must meet to receive reimbursement for services provided to Medicare beneficiaries
Minimum Data Set (MDS) for Long Term Care The instrument specified by CMS that requires nursing facilities to conduct a comprehensive, accurate, standardized, reproducible assessment of each resident's functional capacity.
National Committee for Quality Assurance (NCQA) A private, not for profit accreditation organization whose mission is to evaluate and report on the quality of managed care organizations in the united states
Outcomes and Assessment Information Set (OASIS) A standard core assessment data tool developed to measure the outcomes of adult patients receiving home health services under the Medicare and Medicaid programs
Palliative Care interventions that help the patient achieve comfort but do not affect the course of a disease
Patient Assessment Instrument (PAI) A standardized tool used to evaluate the patient's condition after admission to, and at discharge from the healthcare facility
Patient Self Determination Act (PSA) The federal legislation that requires healthcare facilities to provide written information on the patient's right to issue advance directives and to accept or refuse medical treatment
Patient's Bill of Rights The protections afforded to individuals who are undergoing medical procedures in hospitals or other healthcare facilities; also referred to as patient rights
Personal health record (PHR) a health record where health data and information related to the care of a patient is maintained by the patient
Problem list a designated section of a patient's medical chart that details the most important medical information
Problem-oriented health record a method of recording data about the health status of a patient in a problem-solving system
Progress Notes are the part of a medical record where healthcare professionals record details to document a patient's clinical status or achievements during the course of a hospitalization or over the course of outpatient care.
Recovery room report ncludes postanesthesia noteNurse's notes regarding the patient's condition and surgical siteVital signsIntravenous fluids and other medical monitoring
Resident assessment instrument (RAI) A uniform assessment instrument developed by CMS to standardize the collection of skilled nursing facility patient data; includes MDS 3.0, triggers, and RAP
Resident Assessment Protocol a summary of a long term care resident's medical condition and care requirements
Subjective, Objective, Assessment, Plan (SOAP) a component of the problem-oriented medical record that refers to how each progress note contains decomentation relative to subjective observations, objective observations, assessments, and plans
Source oriented health record In a SOMR or source oriented medical record, the record is kept together by subject matter (labs are all together, progress notes are all together). Progress notes in a SOMR are written in paragraph format.
Transfer record A review of the patient's acute stay along with current status, discharge and transfer orders, that accompanies the aptient when he is transferred to another facility; referral form
Electronic health record (EHR) an evolving concept defined as a systematic collection of electronic health information about individual patients or populations
Created by: lindsay1186