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Chp. 5 (HIT-114)Shan

key terms (flashcards)

Addresssograph machine plastic card containing patient identification; used to imprint info. on ea. report in the patient record.
Admission note progress note documented by the attending m.d. at the time of patient admission.
Admission/Discharge Record (face sheet) contains patient identification( or demo-graphic), finanical, and clinical info (or data). normally filed in the beginning of the chart.
Admitting Dx provisional dx-- working tentative, admission, & preliminary dx obtained from the attending phy.; it is the dx upon which inpatient care is initially based.
**advance directive** legal document that provides instructions as to how patients want to be treated in the event they b/c very ill & there is no reasonalbe hope for recovery.
Advance directive notification form Signed by the patient as proof they were notified of their right to have an advance directive.
Against Medical Advice (AMA) Pt's who sign themselves out of a facility & sign a release from responsibility for discharge.
Alias An assumed name.
Ambulance Report generated by EMT--Emergency medical technicians to document clinical info. such as vital signs,level of consciosness, appearance of the pt. original record kept w/the ambulance company --copy goes to the ED--emergency dept.
Ambulatory Record documents services recieved by a pt who has not been admitted to the hosp. overnight, & includes ancillary services, ED sevices, outpatient(or ambulatory) surgery; also called hospital ambulatory care record.
Ancillary Reports documented by such departments as laboratory, radiology, nuclear medicine to assist physician in dx & treatment of pt's
Ancillary service visit Appearance of an outpt. to a hosp. dept. to recieve an ordered service, test or procedure; also called occasion of service.
anesthesia record required when a pt. recieves an anesthetic other than a local anesthetic to document pt. monitoring during administration of anesthetic agents and other activities related to the surgical episode.
antepartum record gernerated in the physician's office which includes health hx of the mother,family & social hx, pregnancy risk factors, care during pregnancy including tests performed, & medications administered, also called prenatal record.
anti-dumping legislation (EMTALA)-Emergency Medical Treatment & Labor Act:addressed the problem of hospitals failing to screen,treat,or appropriatly transfer patients (pt.dumping)by establishing criteria for the discharge & transfer of HMB & HMAB pt's also called the anti-dumping
APGAR score Measures a baby's appearance(e.g.(A) skin color),pulse(P),grimace(G),(eg.,irritability), activity(A)(eg.,muscle tone & motion), & respirations (R) on a scale of 1 to 10(with up to 2 pts assigned for ea. measurement & 10 being the maximum score).
attestation statement (5)signed by the attending physician to verify diagnonses & procedures documented & coded @ discharged of a hospital pt.;discontinued in 1995.
automatic stop order stop order>as a pt. safety mechanism,state law mandates-standing physician orders are automatically discontinued(stopped),requiring the physician to document a new order.
autopsy an examination of a body after death- to the determind cause of death.
autopsy report To be documented within 60 days and contains summary of pt's clinical hx including diseases,surgical hx, & tx; detailed results.
bedside terminal system Computer system located at the pt's bedside. Used to automate nursing documentation;patient information can be entered,stored retrieved, and displayed.
birth certificate certificate of birth
birth history documents summary of pregnancy,labor & delivery, and newborn's condition @ birth.
case management note progress note documented by a case manager. Outlines a discharge plan that includes case management/social services provided & pt. education.
certificate of birth Record of birth information about the newborn patient & the parents, & identifies medical information regarding the pregnancy & birth of the newborn; also called birth certificate.
certificate of death Contains a record of information regarding the decedent, his or her family, cause of death, and the disposition of the body; also called death certificate.
chief compliant (CC) pt.'s description of medical condition, stated in the pt.'s own words.
clinical data Health information obtained throughout treatment & care of patient.
clinical resume discharge summary
comorbidities pre-existing condition that will, because of its presence with a specific prinicipal diagnosis, cause an increase in the pt's length of stay by at least on day 75% of the cases (e.g. dibetities, enemia)
**complications** additional diagnosis that describe conditions arising after the beginning of hospital observation and treatment & that modify the course of the pt's illness or the medical care required; they prolong the pt's length of stay by at least one day.
condition of admission consent to admission
consulation Provision of health care services by a consulting physician whose opinion or advice is required by another physician.
consultation report Documented by the consultant & includes the consultant's opinion & findings based on a physical examination & review of pt. records.
death certificate certificate of death
dietary progress note Progress note documented by the dietitian(or authorized designee) which includes pt's dietary needs & any dietary observation made by staff.
differential diagnosis Indicates that several diagnoses are being considered as possible.
discharge note Final progress note documented by the attending physician. Includes pt's discharge destination,discharge medications,activity level allowed, & follow-up plan.
discharge order Final physician order documented to release a pt. from a facility.
discharge summary Provides information for continuity of care & facilitates medical staff committee review; documents the pt's hospitalization, including reson(s) for hospitaliztion, course of treatment, and condition at discharge; also called clinical resume.
doctors orders physician orders
DRG Creep upcoding
durable power of attorney health care proxy
emergency record documents the evaluation & treatment of pt's seen in the facility's emergency department for immediate attention of urgent medical conditions or traumatic injuries.
encounter Professional contact between a pt. & a provider who dilivers services or is professionally responsible for services delivered to a pt.
encounter form Commonly used in physician offices to capture charges generated during an office visit & common services provided in the office. AKA superbill or fee slip.
face sheet Contains pt's indentification (or demographic), financial, and clinical information (or data).
facility identification name of the facility,mailing address,and a telephone number, included on each report.
family history review of the medical events in the pt's family, including disease which may be hereditary or present a risk to the patient.
fee slip encounter form
final diagnosis Diagnosis determined after evaluation & documented by the attending physician upon discharge of the patient from the facility.
follow-up progress note daily progress notes documented by the responsible physicians. includes pt's condition,findings on examination,significant changes in condition and/or diagnosis,respose to medications administered,response to clinical treatment,abnormal test finding,and t
forms comittee Established to oversee the process of adding, deleting, and changing forms and to approve forms used in the record.
graphic sheet documents patient's vital signs (e.g., temperture,pulse,respiration,blood pressure,and so on) using graph for easy interpretation of data.
health care proxy Legal document (recognized by New York State) in which the pt. chooses another person to make treatment decisions in the event the pt. becomes incapable of making these decisions.
history documents the pt's chief complaint,history of present illness (HPI),past/family/social history(PFSH) and review of systems (ROS).
history of present illness (HPI) Chronilogical description of pt's present condition from time of onset to present; should include location,quality,severity,duration of the condition, and associated signs and symptoms.
informed consent Process of advising a patient about treatment options and, depending on state laws, the provider may be obligated to disclosed a patient's diagnosis, proposed treatment/surgery,reason for the treatment/surgery,possible complications,likelihood of success,
intergrated progress notes Progness notes documented by physicians,nurses,physical therapists,occupational therapists, and other professional staff members are organized in the same section of the record.
interval history documents a pt's history of present illness and any pertinent changes and physical findings that occurred since a previous inpatient admission if the patient is readmitted within 30 days after discharge for the same condition.
labor and delivery record Records progress of the mother from time of admission through time of delivery; infromation includes time of onset of contractions,severity of contractions,medications administered,patient and fetal vital signs, and progression of labor.
licensed practitioner Required to have a public license/certification to deliver care to patients.
macroscopic Gross examination of tissue; visible to the naked eye.
maximizing code upcoding
medication administration record (MAR) Documents medications administered,data and time of administration, name of drug,dosage,route of administration,and initials of nurse administering medication.
necropsy the character or extent of changes produced by disease.(autopsy)
necropsy report autopsy report
neonatal record Newborn's record that contains a birth history,newborn identification,physical examination,and progress notes.
newborn identification Immediately following birh,footprints and fingerprints of the newborn are created, and a wrist or ankle band is placed on the newborn(with an identical band placed on the mother).
newborn physical examination An assessment of the newborn's condition immediately after birth, including time and date of bith, vital signs, birth weight and lenth, head and chest measurements,general appearance and physical findings.
newborn progress notes Documents information gathered by nurses in the nursery and includes vital signs, skin color, intake and output, weight, medications and treatment, and observations.
non-licensed practitioner Does not have a public license/certification and is supervised by a licensed/certified professional in the delivery of care to patients.
nures notes Documents daily observation about patients, including an initial history of the patient, patient's reactions to treatments, and treatments rendered.
nursing care plan Documents nursing diagnosis as well as interventions used to care for the patient.
nursing discharge summary Documents patient discharge plans and instructions.
nursing documentation Crucial to patient care because the majority of care delivered to inpatients is performed by nursing staff.
obstetrical record Mother's record that contains an antepartum record, labor and delivery record, and postpartum record.
occasion of service ancillary service visit(e.g. labs,ordered service,or procedure).
operative report describes gross findings,organs examined(visually or palpated),and techniques associated with the performace of surgery.To be dictated or handwritten immediately following the operation and authenticated by the responsible surgeon.
outpatient visit Visit of a patient on one calendar day to one or more hospital departments for the purpose of receiving outpatient health care services.
Past history summary of past illnesses,operations,injuries,treatments, and known allergies.
pathology report Assists in the analysis and treatment of patients by documenting the analysis of tissue removed surgically or diagnostically, or that expelled by the patients; also called tissue report.
patient identification pt's name and some other piece of identifying information such as medical record number, date of birth,or social security number.
patient property form Records items patients bring with them to the hospital.
patient record commitee forms committee
phycial examination Assessment of the pt's body systems to assist in determining a diagnosis, documenting a provisional diagnosis, which may include differential diagnoses.
physician office record documents patient health care services recieved in a physician's office.
physician orders Direct the diagnostic and therapeutic patient care activities; also called doctors orders.
postanesthesia note Progress note documented by the anethesiologist.
postmortem report autopsy report
postoperative note Progress note documented by the surgeon after surgery.Documents the pt's response to surgery and a postoperative diagnosis.
postpartum record Documents information concerning the mother's condition after delivery.
preanesthesia evaluation note Progress note documented by the anesthesiologist prior to the induction of anesthesia.
prenatal record antepartum record
preoperative note Progress note documented by the surgeon prior to surgery. Summarizes the pt's condition and documents a preoperative diagnosis.
primary diagnosis Reason the patient sought treatment during that encounter; reflects the current, most significant reason for services provided or procedures performed.
**principal diagnosis** condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care.
**principal procedure** Procedure performed for definitive or therapeutic reasons,rather than diagnostic purposes, or to treat a complication, or that procedure which is most closely related to the principal diagnosis.
progress notes Contain statements related to the course of the patient's illness,response to treatment, and status at discharge.
provisional autopsy report Contains a cause fo death and is to be documented within 72 hours(3days).
read and varified (RAV) Abbreviation entered by staff member who documents a telephone order to document that the telephone order call-back policy was followed.
recovery room record Delineates care administerd to the patient from the time of arrival until the patient is moved to a nursing unit.
rehabilitation therapy progress note Progress notes documented by various rehabilitation therapists that demonstrated the pt's progress(or lack thereof)toward established therapy goals.
respiratory therapy progress note Progress notes documented by respiratory therapists.
review of systems Inventory by systems to reveal subjective symptoms stated by the patient; provides an opportunity to gather information that the patient may have forgotten to mention or that may have seemed unimportant.
routine order Physician orders preapproved by the medical staff,which are preprinted and placed on a pt's record.
**secondary diagnosis** additional conditions for which the patient received treatment and/or impacted the inpatient care.
**secondary procedure(s)** additional procedure(s) performed during inpatient admission.
short stay An uncomplicated hospital stay of less than 48 hours.
short stay record Allows providers to record the patient's history, physical examination,progress notes,physician orders, and nursing documentation on one double-sided form.
social history Age-appropriate review of past and current activities such as daily routine,dietary habits,excercise routine, marital status,occupation,sleeping patterns,smoking,use of alcohol and other drugs,sexual activities,and so on.
standing order physician orders preapproved by the medical staff that direct the continual administration of specific acitivities for a specific period of time as a part of diagnostic or therapeutic care.
stop order as a pt. safety mechanism,state law mandates, and in the absence of state law facilities decide,for which circumstances preapproved standing physician orders are automatically discontinued (stopped),requiring the physician to document a new order.
superbill encoutner form
telephone order call back policy requires the authorized staff member to read back and verify what the physician dictated to ensure that the order is entered accuratley.
tissue report pathology report
transfer order physician order documented to transfer a patient from one facility to another.
Uniform Ambulatory Care Data Set (UACDS) Minimum core data set collected on Medicare oand Medicaid outpatients.
Uniform Hospital Discharge Data Set (UHDDS) Minimum core data set collected on individual hospital dicharges for the Medicare and Medicaid programs; much of this information is located on the face sheet.
**upcoding** documentation of diagnosis and procedures that result in higher payment for a facility;also call maximizing codes or DRG Creep.
verbal order Orders dictated to an authorized facility staff member because the responsible physician is unable to personally document the order.
written order Orders that are handwritten in a paper-based record or entered into an electronic health record by the responsible physician.