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Chapter 4
HIT 114 Chapter 4
| Question | Answer |
|---|---|
| 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 |
| audit trail | CONTROL CREATED BY AN ELECTRONIC HEALTH SYSTEM AND LIST ALL THE TRANSACTIONS AND ACTIVITIES THAT HAVE Occured. |
| 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
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