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Chapter 4

HIT 114 Chapter 4

alternative care facilities provide behavioral health, home health, hospice, outpatient,skilled nursing and other formas of care also serve as documentation patient care information.
patient record a business record for a patient encounter, contains dicumentation of all health services.
demographic data patient identifiction information collected according to facility policy and includes patient's name and other info such as date of birth, birthplace, mother's name etc...
Information capture process of recording representations of human thought, preceptions, or actions in documentating patient care, as well as device generated information that is gathered and computed about a patient as part of health care.
report generation construction of a healthcare document, consists of formatting and structuring of captured information
continuity of care the primary purpose of the patient record.
hospital impatient record documents the care and treatment received by a patient admitted to the hospital
administrative data includes demograhphic, socioeconomic, and financial data
clinical data includes all info about the patients health and treatment throught the care process
hospital outpatient record documents services received by a patient who has not been admitted into the hospital
authentication the entry must be signed by the author
countersignature a form of authentication by an individual in addition to the signature of the orginal author
telephone order is a verbal order over the phone by a qualified professional from aphysician
voice order the physician dictates an order in the presence of a responsible person. this practce is no longer used.
signature legend a complete signature that matches initial that are on a record
electronic signatures is a generic term that refers to the variuos methods of electronic documents that are authenticated electronically.
digital signature is created using a public key cryptograophy to authtenticate a dicument
public key cryptography uses an algothrium of 2 keys , one for creating the digital signature by transforming data and other to verify the key.
signature stamps a stamp that has an authorized signature on it
abbreviation list includes a list of medical abbreviation that are approved by staff
deliquent records records that aren't processed before the 30 days mark after a patient is discharged
amending the patient record occasionally correct documentaion in the patient record
addendum an addition to the orignal chart entry
preadmission testing incorporates patient registration, testing, and other services into one visit prior to inpatient admission
provisional diagnosis preliminary diagnosis obtained from the attending physicican
patient representative the person who has legal responsibility over the patient
nursing assesment documents on the patients historty, medications, vitals, and nurses notes.
reverse chronological date order the most current document is on top
chronological date order arranged from first to last
solo practicioner a physician that practices alone
secondary sourses patient information contains data abstracted from primary sourses of patient info
manual record a paper record
incidnt report collects info about a potentially compensable event
PCE accident or injury report
source orentiated record maintains reports according to source of documentation
sectionalized records records divided into sections
problem oriented recors consists of 4 areas. database, problem list, initial plan, progress notes
database contains minimum set of data to be collected on eah patient
problem list acts as a table of contents for the overview of patient information and problems
initial plan describes actions that will be taken to learn more about the patients condition adn treatment
diagnostice/management plans plans to learn more about the patients condition and the management of the conditions
theraputic plans specific medications, goals, procedures, therapies, and treatments ised to treat the patient
patients education plans plans to educate the patient about the conditions for which the patient is being treated
subjective the patients statement about how they feel, including symptoms
objective observations about the patient such as physical findings or lab or xray results
Created by: ashbug207