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Chapter 5
Key Terms, shannon's class
| Question | Answer |
|---|---|
| ADDRESSOGRAPH MACHINE | PLASTIC CARD CONTAINING PATIENT ID; USED TO IMPRINT INFORMATION ON EACH REPORT IN THE PATIENT RECORD. |
| ADMISSION NOTE | PROGRESS NOTE DOCUMENTED BY THE ATTENDING PHYSICIAN @ THE TIME OF ADMISSION; INCLUDES REASON FOR ADMISSION,DESCRIPTION OF PATIENT'S CONDITION,BRIEF HISTORY OF PRESENT ILLNESS,PATIENT CARE PLAN,METHOD/MODE OF ARRIVAL,RESPONSE TO ADMISSION,AND PHYSICAL ASSE |
| ADMISSION /DISCHARGE RECORD(FACE SHEET) | CONTAINS PATIENT ID (DEMOGRAPHIC),FINANCIAL AND CLINICAL INFO (OR DATA). USUALLY FILED AS THE FIRST PAGE OF THE PATIENT RECORD BECAUSE IT IS FREQUENTLY REFERENCED. |
| ADMITTING DIAGNOSIS(PROVISIONAL DIAGNOSIS) | WORKING, TENTATIVE, ADMISSION, AND PRELIMINARY DIAGNOSIS OBTAINED FROM THE ATTENDING PHYSICIAN; IT IS THE DIAGNOSIS 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 BECOME VERY ILL AND THERE IS NO REASONABLE HOPE FOR RECOVERY. WRITTEN INSTRUCTIONS DIRECT A HEALTH CARE PROVIDER REGARDING A PATIENT'S PREFERENCES FOR CARE. |
| 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) | PATIENTS WHO SIGN THEMSELVES OUT OF A FACILITY AND SIGN A RELEASE FROM RESPONSIBILITY FOR DISCHARGE. |
| ALAIS | AN ASSUMED NAME. |
| AMBULANCE REPORT | GENERATED BY EMT'S TO DOCUMENT CLINICAL INFORMATION SUCH AS VITAL SIGNS,LEVEL OF CONSCIOUSNESS,APPEARANCE OF THE PATIENT,AND SO ON. A COPY OF THE AMULANCE REPORT IS PLACED IN THE EMERGENCY DEPARTMENT RECORD; THE ORIGINAL AMBULANCE REPORT IS THE PROPERTY O |
| AMBULATORY RECORD/ HOSPITAL OUTPATIENT RECORD | DOCUMENTS SERVICES RECEIVED BY A PATIENT WHO HAS NOT BEEN ADMITTED TO THE HOSPITAL OVERNIGHT, AND INCLUDES ANCILLARY SERVICES, EMERGENCY DEPARTMENT SERVICES, AND OUTPATIENT(OR AMBULATORY) SURGERY. |
| ANCILLARY REPORT | DOCUMENTED BY SUCH DEPARTMENTS AS LABORATORY, RADIOLOGY, NUCLEAR MEDICINE TO ASSIST PHYSICIANS IN DIAGNOSIS AND TREATMENT OF PATIENTS. |
| ANCILLARY SERVICE VISIT/OCCASION OF SERVICE | APPEARANCE OF AN OUTPATIENT TO A HOSPITAL DEPARTMENT TO RECEIVE AN ORDERED SERVICE, TEST OR PROCEDURE. |
| ANESTHESIA RECORD | REQUIRED WHEN A PATIENT RECEIVES AN ANESTHETIC OTHER THAN A LOCAL ANESTHETIC TO DOCUMENT PATIENT MONITORING DURING ADMINISTRATION OF ANESTHETIC AGENTS AND OTHER ACTIVITIES RELATED TO THE SURGICAL EPISODE. |
| ANTEPARTUM RECORD/PRENATAL RECORD | GENERATED IN THE PHYSICIAN'S OFFICE AND INCLUDES HEALTH HISTORY OF THE MOTHER, FAMILY AND SOCIAL HISTORY,PREGNANCY RISK FACTORS,CARE DURING PREGNANCY INCLUDING TESTS PERFORMED, AND MEDICATIONS ADMINISTERED |
| ANTI-DUMPING LEGISLATION/(EMTALA)-EMERGENCY MEDICAL TREATMENT AND LABOR ACT | ADDRESSED THE PROBLEM OF HOSPITALS FAILING TO SCREEN, TREAT, OR APPROPRIATELY TRANSFER PAATIENTS(PATIENT DUMPING) BY ESTABLISHING CRITERIA FOR THE DISCHARGE AND TRANSFER OF MEDICARE AND MEDICAID PATIENTS;ANTI-DUMPING STATUTE. |
| APGAR SCORE | MEASURES A BABY'S (A)APPEARANCE,(P)PULSE,(G)ACTIVITY,(A)AND RESPIRATIONS ON A SCALE OF 1-10 |
| ATTESTATION STATEMENT | SIGNED BY THE ATTENDING PHYSICIANS TO VERIFY DIAGNOSES AND PROCEDURES DOCUMENTED AND CODED AT DISCHARGE OF A HOSPITAL PATIENT; DISCONTINUED IN 1995. |
| AUTOMATIC STOP ORDER/STOP ORDER | AS A PATIENT SAFETY MECHANISM,STATE LAW MANDATES, AND IN THE ABSCENCE OF STATE LAW FACILITIES DECIDE, FOR WHICH CIRCUMSTANCES PREAPPROVED STANDING PHYSICIANS ORDERS ARE AUTOMATICALLY DISCONTINUED (STOPPED), REQUIRING THE PHYSICIAN TO DOCUMENT A NEW ORDER. |
| AUTOPSY/NECROPSY | AN EXAMINATION OF A BODY AFTER DEATH. INCLUDES THE MACROSCOPIC AND MICROSCOPIC EXAMINATION OF VITAL ORGANS AND TISSUE SPECIMENS TO ASSIST IN DETERMINING A CAUSE OF DEATH AND THE CHARACTER OR EXTENT OF CHANGES PRODUCED BY DISEASE. |
| AUTOPSY REPORT | TO BE DOCUMENTED 60 DAYS AND CONTAINS SUMMARY OF PATIENT'S CLINICAL HISTORY INCLUDING DISEASES, SURGICAL HISTORY, AND TREATMENT;DETAILED RESULTS OF THE FINDINGS APPEARANCE OF THE BODY AND INTERNAL EXAM BY BODY SYSTEM CONTRIBUTING FACTORS THAT LED TO DEATH |
| BEDSIDE TERMINAL SYSTEM | COMPUTER SYSTEM LOCATED AT THE PATIENT'S BEDSIDE. USED TO AUTOMATE NURSING DOCUMENTATION; PATIENT INFORMATION CAN BE ENTERED, STORED, RETRIEVED, AND DISPLAYED. |
| BIRTH CERTIFICATE/CERTIFICATE OF BIRTH | RECORD OF BIRTH INFORMATION ABOUT NEWBORN PATIENT AND THE PARENTS, AND IDENTIFIES MEDICAL INFORMATION REGARDING THE PREGNANCY AND BIRTH OF THE NEWBORN. |
| BIRTH HISTORY | DOCUMENTS SUMMARY OF PREGNANCY, LABOR, AND DELIVERY; AND NEWBORN'S CONDIION AT BIRTH. |
| CASE MANAGEMENT NOTE | PROGRESS NOTE DOCUMENTED BY A CASE MANAGER. OUTLINES A DISCHARGE PLAN THAT INCLUDES CASE MANAGEMENT/SOCIAL SERVICES PROVIDED AND PATIENT EDUCATION. |
| CERTIFICATE OF DEATH | CONTAINS A RECORD OF INFORMATION REGARDING THE DECEDENT, HIS OR HER FAMILY, CAUSE OF DEATH AND THE DISPOSITION OF THE BODY. |
| CHIEF COMPLAINT(CC) | PATIENT'S DESCRIPTION OF MEDICAL CONDITION, STATED IN THE PATIENT'S OWN WORDS. |
| CLINICAL DATA | HEALTH INFORMATION OBTAINED THROUGHOUT TREATMENT AND CARE OF PATIENT, INCLUDES HEALTH CARE INFORMATION OBTAINED ABOUT A PATIENT'S CARE AND TREATMENT, WHICH IS DOCUMENTED ON NUMEROUS FORMS IN THE PATIENT RECORD. |
| CLINICAL RESUME/DISCHARGE SUMMARY | PROVIDES INFORMATION FOR CONTUNUITY OF CARE AND FACILITATES MEDICAL STAFF COMMITTEE REVIEW; DOCUMENTS THE PATIENT'S HOSPITALIZATION,INCLUDING REASON(S) FOR HOSPOTALIZATION, COURSE OF TREATMENT, AND CONDITION AT DISCHARGE. |
| COMORBIDITIES | PRE-EXISTING CONDITION THAT WILL, BECAUSE OF ITS PRESENCE WITH A SPECIFIC PRINCIPAL DIAGNOSIS, CAUSE AN INCREASE IN THE PATIENT'S LENGTH OF STAY BY AT LEAST ONE DAY IN 75% OF THE CASES. |
| COMPLICATIONS | ADDITIONAL DIAGNOSES THAT DESCRIBE CONDITIONS ARISING AFTER THE BEGINNING OF HOSPITAL OBSERVATION AND TREATMENT AND THAT MODIFY THE COURSE OF THE PATIENT'S ILLNESS OR THE MEDICAL CARE REQUIRED; THEY PROLONG THE PATIENT'S LENGTH OF STAY BY AT LEAST ONE DAY |
| CONDITIONS OF ADMISSION/CONSENT TO ADMISSION | A GENERALIZED CONSENT THAT DOCUMENTS A PATIENT'S CONSENT TO RECEIVE MEDICAL TREATMENT AT THE FACILITY. |
| CONSULTATION | PROVISION OF HEALTH CARE SERVICES BY A CONSULTING PHYSICIAN WHOSE OPINION OR ADVICE IS REQUESTED BY ANOTHER PHYSICIAN. |
| CONSULTATION REPORT | DOCUMENTED BY THE CONSULTANT AND INCLUDES THE CONSULTANT'S OPINION AND FINDINGS BASED ON A PHYSICAL EXAMINATION AND REVIEW OF PATIENT RECORDS. |
| DIETATY PROGRESS NOTE | PROGRESS NOTE DOCUMENTED BY THE DIETITIAN (OR AUTHORIZED DESIGNEE). INCLUDES PATIENT'S DIETARY NEEDS AND ANY DIETARY OBSERVATIONS MADE BY STAFF. |
| DIFFERENTIOAL DIANOSIS | INDICATES THAT SEVERAL DIAGNOSES ARE BEING CONSIDERED AS POSSIBLE. |
| DISCHARGE NOTE | FINAL PROGRESS NOTE DOCUMENTED BY THE ATTENDING PHYSICIAN. INCLUEDS PATIENT'S DISCHARGEE DESTINATION, DISCHARGE MEDICATIONS. ACITVITY LEVEL ALLOWED, AND FOLLOW-UP PLAN. |
| DISCHARGE ORDER | FINAL PHYSICIAN ORDER DOCUMENTED TO RELEASE A PATIENT FROM A FACILITY. |
| DISCHARGE SUMMARY/CLINICAL RESUME | PROVIDES INFORMATION FOR CONTINUITY OF CARE AND FACILITATES MEDICAL STAFF COMMTTEE REVIEW; DOCUMENTS THE PATIENT'S HOSPITALIZATION,INCLUDING REASON(S) FOR HOSPITALIZATION, COURSE OF TREATMENT, AND CONDITION AT DISCHARGE. |
| DOCTORS ORDERS/PHYSICIAN ORDERS | DIRECT THE DIAGNOSTIC AND THERAPEUTIC PATIENT CARE ACTIVITIES. |
| DRG CREEP/UPCODING | DOCUMENTATION OF DIAGNOSES AND PROCUDURES THAT RESULT IN HIGHER PAYMENT FOR A FACILITY; ALSO CALLED MAXIMIZING CODES. |
| DURABLE POWER OF ATTORNEY/ HEALTH CARE PROXY | LEGAL DOCUMENT (RECOGNIZED BY NEW YOUK STATE) IN WHICH THE PATIENT CHOOSES ANOTHER PERSON TO MAKE TREATMENT DECISIONS IN THE EVENT THE PATIENT BECOMES INCAPABLE OF MAKING THESE DECISIONS. |
| EMERGENCY RECORD | DOCUMENTS THE EVALUATION AND TRETMENT OF PATIENTS SEEN IN THE FACILITY'S EMERGENCY DEPARTMENT FOR IMMEDIATE ATTENTION OF URGENT MEDICAL CONDITIONS OR TRAUMATIC INJURIES. |
| ENCOUNTER | PROFESSIONAL CONTACT BETWEEN A PATIENT AND A PROVIDER WHO DELIVERS SERVICES OR IS PROFESSIONALLY RESPOSIBLE FOR SERVICES DELIVERED TO A PATIENT. |
| ENCOUNTER FORM/ SUPER BILL/ FEE SLIP | COMMONLY USED IN PHYSICIAN OFFICES TO CAPUTRE CHARGES GENERATED DURING AN OFFICE VISIT AND CONSISTS OF A SINGLE PAGE THAT CONTAINS A LIST OF COMMON SERVICES PROVIDED IN THE OFFICE. INITIATED WHEN THE PATIENT REGISTERS AT THE FORNT DESK AND IS COMPLETED BY |
| FACE SHEET/ ADMISSION/DISCHARGE RECORD | CONTAINS PATIENT IDENTIFICATION ( OR DEMOGRAPHIC) FINANCIAL, AND CLINICAL INFORMATION (OR DATA). USUALLY FILED AS THE FIRST PAGE OF THE PATIENT RECORD BECAUSE IT IS FREQUENTLY REFERENCED. |
| FACILITY IDENTIFICATION | NAME OF THE FACIITY, MAILING ADDRESS, AND A TELEPHONE NUMBER; INCLUDED ON EACH REPORT IN THE RECORD SO THAT AN INDIVIDUAL OR HEALTH CARE FACILITY IN RECEIPT OF COPIES OF THE RECORD CAN CONTACT THE FACILITY FOR CLARIFICATION OF RECORD CONTENT. |
| FAMILY HISTORY | REVIEW OF THE MEDICAL EVENTS IN THE PATIENT'S FAMILY, INCLUDING DISEASES WHICH MAY BE HEREDITARY OR PRESENT A RISK TO THE PATIENT. |
| FEE SLIP/ ENCOUNTER FORM | COMMONLY USED IN PHYSICIAN OFFICES TO CAPUTRE CHARGES GENERATED DURING AN OFFICE VISIT AND CONSISTS OF A SINGLE PAGE THAT CONTAINS A LIST OF COMMON SERVICES PROVIDED IN THE OFFICE, INITIATED WHEN THE PATIENT REGISTERS AT THE FRONT DESK AND IS COMPLETED B |
| FINAL DIAGNOSIS | DIAGNOSIS DETERMINED AFTER EVALUATION AND 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.INCLUDE PATIENT'S CONDITION,FINDINGS ON EXAMINATION,CHANGES IN CONDITION AND OR DIAGNOSIS,RESPONSE TO MEDICATIONS ADMINISTERED,RESPONSE TO CLINICAL TREATMENT,ABNORMAL TEST FINDINGS,AND TREATMEN |
| FORMS COMMITTEE | 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 USING A GRAPH FOR EASY INTERPRETATION OF DATA. |
| HEALTH CARE PROXY | LEGAL DOCUMENT (RECOGNIZED BY NEW YORK STATE) IN WHICH THE PATIENT CHOOSES ANOTHER PERSON TO MAKE TREATMENT DECIIONS IN THE EVENT THE PATIENT BECOMES INCAPABLE OF MAKING THESE DECISIONS. |
| HISTORY | DOCUMENTS THE PATIENT'S CHIEF COMPLAINT, HISTORY OF PRESENT ILLNESS (HPI), PAST/FAMILY/SOCIAL HISTORY(PFSH) AND REVIEW OF SYSTEMS (ROS). INDIVIDUAL RESPONSIBLE FOR DOCUMENTING THE HISTORY SHOULD OBTAIN THE INFORMATION DIRECTLY FROM THE PATIENT AND SHOULD |
| HISTORY OF PRESENT ILLNESS (HPI) | CHRONOLOGICAL DESCRIPTION OF PATIENT'S PRESENT CONITION FROM TIME OF ONSET TO PRESENT; SHOULD INCLUDE LOCATION, QUALITY. SEVERITY, DURATION OF THE CONDITIONM 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 DISCLOSR A PATIENT'S DIAGNOSIS, PROPOSED TREATMENT/SURGERY, POSSIBLE COMPLICATIONS, LIKELIHOOD OF SUCCES, ALTERNATIVE TREATMENT OPTIONS, AN |
| INTEGRATED PROGRESS NOTES | PROGRESS NOTES DOCUMENTED BY PHYSICIANSM, NURSESM, PHYSICAL THERAPISTS, OCCUPATIONAL THERAPISTS, ANDS OTHER PROFESSIONAL STAFF MEMBERS ARE ORGANIZED IN THE SAME SECTION OF THE RECORD. ALLOW THE PATIENT'S COURSE OF TREATMENT TO BE EASILY FOLLOWED BECAUSE A |
| INTERVAL HISTORY | DOCUMENTS A PATIENT'S HISTORY OF PRESENT ILLNESS AND ANY PERTINENT CHANGES AND PHYSICAL FINDINGS THAT OCCCURRED SINCE A PREVIOUS INPATIENT ADMISSION IF THE PATIENT IS READMITTED WITHIN 30 DAYS AGTER DISCHARGE FOR THE SAME CONDITION. ORIGINAL HISTORY AND P |
| LABOR AND DELIVERY RECORD | RECORDS PROGRESS OF THE MOTHER FROM TIME OF ADMISSION THROUGH TIMEOF DELIVERY; INFORMATION INCLUDES TIME OF ONSET OF CONTRACTIONS,SEVRITY OF CONTACTIONS, MREDICAIONDS ADMINISTERED, PATIENT AND FETAL VITAL SIGNS, AND PROGRESSION OF LABOR. |
| LICENSED PRACTITIONER | REQUIRED TO HAVE A PUBLIC LOCENSE/CERTIFICATION TO DELIVER CARE TO PATIENTS. |
| MACROSCOPIC | GROSS EXAMINATION OF TISSUE; VISIBLE TO THE NAKED EYE. |
| MAXIMIZING CODES/UPCODING | DOCUMENTATION OF DIAGNOSES AND PROCEDURES THAT RESULT IN HIGHER PAYMENT FOR A FACILITY. |
| MEDICATION ADMINISTRATION RECORD (MAR) | DOCUMENTS MEDICATIONS ADMINISTERED, DATE AD TIME OF ADMINISTRATION, NAME OF DRUG, DOSAGE, ROTE OF ADMINISTRATION, AMD INITIALS OF NURSE ADMINISTERING MEDICATION. |
| NECROPSY/AUTOPSY | AN EXAMINATION OF A BODY AFTER DEATH. INCLUDES THE MACROSCOPIC AND MICROSCOPIC EXAMINATION OF VITAL ORGANS AND TISSUE SPECIMENS TO ASSIST IN DETERMINING A CAUSE OF DEATH AND THE CHARACTER OR EXTENT OF CHANGES PRODUCED BY DISEASE. |
| NECROPSY REPORT/AUTOPSY REPORT | TO BE DOCUMENTED WITHIN 60 DAYS AND CONTAINS SUMMARY OF PATIENT'S CLINICAL HISTORY INCLUDING DISEASES, SURGICAL HISTORY, AND TREATMENT; DETAILED RESULTS OF THE MACROSCOPIC AND MICROSCOPIC FINDINGS, INCLIDING EXTERNAL APPEARANCE OF THE BODY AND INTERNAL EX |
| NEONATAL RECORD | NEWBORN'S RECORD THAT CONTAINS A BIRTH HISTORY, NEWBORN IDENTIFICATION, PHYSICAL EXAMINATION, AND PROGRESS NOTES. |
| NEWBORN PHYSICAL EXAMINATION | AN ASSESSMENT OF THE NEWBORN'S CONDITION IMMEDIATELY AFTER BIRTH, INCLUDING TIME AND DATE OF BIRTH, VITAL SIGNS, BIRTH WEIGHT AND LENGTH, HEAD AND CHEST MEASUREMENTS, GENERAL APPEAEANCE 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 TREATMENTS, AND OBSERVATIONS. |
| NON-LICENSED PRACTITIONER | DOES NOT HAVE A PUBLIC LICENSE/CERTIFICATIO NAN IS SUPERVISED BY A LICENSED/CERTIFIED PROFESSIONAL IN THE DELIVERY OF CARE TO PATIENTS. |
| NURSES NOTES | DOCUMENTS DAILY OBSERVATION ABOUT PATIENTS, INCLUDING AN INITIAL HISTORY OF THE PATIENT, PATIENTS REACTIONS TO TREATMENTS, AND TREATMENTS RENDERED. |
| NURSING CARE PLAN | DOCUMENTS NURSING DIAGNOSES AS WELL AS INTERBENTIONS 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 POSTPARURM RECORD. |
| OCCASION OF SERVICE/ANCILLARY SERVICE VISIT | APPEARANCE OF AN OUTPATIENT TO A HOSPITAL DEPARTMENT TO RECEIVE AN ORDERED SERVICE, TEST OR PROCUDURE. |
| OPERATIVE RECORD | DESCRIBES GROSS FINDINGS, ORGANS EXAMINED (VISUALLY OR PALPATED), AND TECHNIQUES ASSOCIATED WITH THE PERFORMANCE OF SURGERY. TO BE DICTATED OR HANDWRITTEN IMMEDIATELY FOLLOWING THE OPERTION ANDAUTHENTICATED BY THE RESONSIBLE 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/ TISSUE REPORT | ASSISTS IN THE DIAGNOSIS AND TREATMENT OF PATIENTS BY DOCUMENTING THE ANALYSIS OF TISSUE REMOVED SURGICALLY OR DIAGNOSTICALLY, OR THAT EXPELLED BY THE PATIENT. |
| PATIENT IDENTIFICATION | PATIENT'S NAME AND SOME OTHER PIECE OF IDENTIFYING INFORMATION SUCH AS MEDICAL RECORD NUMBER, DATE OF BIRTH, OR SOCIAL SECURITY NUMBER; EVERY REPORT IN THE PATIENT RECORDAND EVERY SCREEN IN AN AUTOMATED RECORD SYSTEM MUST INCLUDE PATIENT IDENTIFICATION. |
| PATIENT PROPERTY FORM | RECORDS ITEMS PATIENTS BRING WITH THEM TO THE HOSPITAL. |
| PATIENT RECORD COMMITTEE/ FORMS COMMITTEE | ESTABLISHED TO OVERSEE THE PROCESS OF ADDING , DELETING, AND CHANGING FORMS AND TO APPROVE FORMS USED IN THE RECORD. |
| PHYSICAL EXAMINATION | ASSESSMENT OF THE PATIENT'S BODY SYSTEMS TO ASSIST IN DETERMINING A DIAGNOSIS, DOCUMENTING A PROVISIONAL DIAGNOSIS, WHICH MAY INCLUDE DIFFERENTIAL DIAGNOSIS. |
| PHYSICIAN OFFICE RECORD | DOCUMENTS PATIENT HEALTH CARE SERVICES RECEIVED IN A PHYSICIAN'S OFFICE. SHOULD CONTAIN PATIENT REGISTRATION INFORMATION, A PROBLEM LIST, A MEDICATION RECORD, PROGRESS NOTES(INCLUDING PATIENT'S HISTORY AND PHYSICAL EXAMINATION), AND RESULTS OF ANCILLARY R |
| PHYSICIAN ORDERS/ DOCTORS ORDERS | DIRECT THE DIAGNOSTIC AND THERAPEUTIC PATIENT CARE ACTIVITIES. |
| POSTANESTHESIA NOTE | PROGRESS NOTE DOCUMENTED BY THE ANESTHESIOLOGIST. INCLUDES PATIENT'S GENTERAL CONDITIONFOLLOWING SURGERY, DESCRIPTION OF PRESENCE/ABSENCE OF ANESTHESIA-RELATED COMPLICATIONS AND OR POSTOPERATIVE ABNORMALITIES, BLOOD PRESSURE, PULSE,PRESENCE/ABSENCE OF SWA |
| POSTMORTEM REPORT | TO BE DOCUMENTED WITHIN 60 DAYS AND CONTAINS SUMMARY OF PATIENT'S CLINICAL HISTORY INCLUDING DISEASES, SURGICAL HISTORY, AND TREATMENT; DETAILED RESULTS OF THE MACROSCOPIC AND MICROSCOPIC FINDINGS, INCLUDING EXTERNAL APPEARANCE OF THE BODY AND INTRNAL EXA |
| POSTOPERATIVE NOTE | PROGRESS NOTE DOCUMENTED BY THE SURGEON AGTER SURGERY DOCUMENTS THE PATIENT'S RESPONSE TO SURGERY AND A POSTOPERATIVE DIAGNOSIS. |
| POSTPARTUM RECORD | DOCUMENTS INFORMATION CONCERNING THE NOTHER'S CONDITION AGTER DELIVERY. |
| PREANESTHESIA EVALUATION NOTE | PROGRESS NOTES DOCUMENTED BY THE ANESTHESIOLOGIST PRIOR TO THE INDUCTION OF ANESTHESIA. INCLUDES EVIDENCE OF PATIENT INTERVIEW TO VERIFY PAST AND PRESENTMEDICAL AND DRUG HISTORY AND PREVIOUS ANESTHESIA EXPERIENCE(S), EVAULATION OF THE PATIENT'S PHYSICAL S |
| PRENATAL RECORD/ ANTEPARTUM RECORD | GENERATED IN THE PHYSICIAN'S OFFICE AND INCLUDES HEALTH HISTORY OF THE MOTHER, FAMILY AND SOCIAL HISTORY, PREGNANCY RISKS FACTORS, CARE DURING PREGNANCY INCLUDING TESTS PERFORMED, AND MEDICATIONS ADMINISTERED. |
| PREOPERATIVE NOTE | PROGRESS NOTE DOCUMENTED BY THE SURGEON PRIOR TO SURGERY. SUMMARIZES THE PATIENT'S CONDITION AND DOCUMENTS A PREOPERATIVE DIAGNOSIS. |
| PRIMARY DIAGNOSIS | REASON THE PATIENT SOUGHT TREATMENT DURING THAT ENCOUNTER; REFLEXS THE CURRENT, MOST SIGNIFICANT REASON FOR SERVICES PROVIDED OR PROCVEDURES 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 PRINCIPLE DIAGNOSIS. |
| PROGRESS NOTES | CONTAIN STATEMETNTS RELATED TO THE COURSE OF THE PATIENT'S ILLNESS, RESPONSE TO TREATMENT, AND STATUS AT DISCHARGE. THEY FACILITATE HEALTH CARE TEAM MEMBER COMMUNICATION BECAUSE PROGRESS NOTES PROVIDE A CHRONOLOGICAL PICTURE AND ANALSIS OF THE PATIENT'S C |
| PROVISIONAL AUTOPSY REPORT | CONTAINS A CAUSE OF DEATH AND IS TO BE DOCUMENTED WITHIN 72 HOURS. |
| READ AND VERIFIED (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 ADMINISTRATED TO THE PATIENT FROM THE TIME OF ARRIVAL UNTIL THE PATIENT IS MOVED TO A NURSING UNIT. |
| REHABILITAITION THERAPY PROGRESS NOTE | PROGRESS NOTES DOCUMENTED BY VARIOUS REHABILITATION THERAPISTS THAT DEMONSTRATE THE PATIENT'S PROGRESS(OR LACK THEREOF) TOWARD ESTABLISHED THERAPY GOALS. |
| RESPIRATORY THERAPY PROGRESS NOTE | PROGRESS NOTES DOCUMENTED BY RESPIRATORY THERAPISTS. INCLUDE THERAPY ADMINISTERED, MACHINES USED, MEDICATION(S) ADDED TO MACHINES, TYPE OF THERAPY, DATES/TIMES OF ADMINISTRATION, SPECIFICATIONS OF THE PRESCRIPTION, EFFECTS OF THERAPY INCLUDING ANY ADVERSE |
| REVIEW OF SYSTEMS (ROS) | INVENTORY BY SYSTEMS TO REVEAL SUBJECTIVE SYMPTONS 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 PATIENT'S RECORD. INCLUDE STANDARD ADMITTING ORDERS FOR A SURGICAL PATIENT, DISCHARGE ORDERS FOLLOWING SURGERY, AND SO ON. |
| SECONDARY DIAGNOSES | ADDITIONAL CONDITIONS FOR WHICH THE PATIENT RECEIVED TREATMENT AND/OR IMPACTED THE INPATIENT CARE. |
| SECONDARY PROCEDURES | ADDITIONAL PROCUDURE(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 ORDERDS, AND NURSING DICMENTATION ON ONE DOUBLE-SIDED FORM. |
| SOCIAL HISTORY | AGE-APPROPRIATE REVIEW OF PAST AND CURRENT ACTIVITIES SUCH AS DAILY ROUTINE, DIETARY HABITS, EXERCISE ROUTINE, MARITAL STATUS, OCCATION, SLEEPING PATTERNS, SMOKING, USE OF ALCOHOL AND OTHER DRUGS, SEXUAL ACTIVITEDS, AND SO ON. |
| STANDING ORDER | PHYSICIAN ORDERS PREAPPROVED BY THE MEDICAL STAFF THAT DIRECT THE CONTINUAL ADMINISTRATION OF SPECIFIC ACTIVITIES FOR A SPECIFIC PERIOD OF TIME AS A PART OF DIAGNOSTIC OR THERAPEUTIC |
| STOP ORDER | OAS A PATIENT SAFETY MECHANISM, STATE LAW ANDATES, AND IN THE ABENCE OF STATE LAW FACIITIES DECIDE, FOR WHICH CIRCUMSTANCES PREAPPROVED STANDING PHYSICIAN ORDERS ARE AUTOMATICALLY DISCONTINUED (STOPPED), REQUIREING THE PHYSICIAN TO DOCUMENT A NEW ORDER. |
| SUPERBILL/ ENCOUNTER FORM/ FEE SLIP | COMMONLY USED IN PHYSICIAN OFFICES TO CAPTURE CHARGES GENEATED DURING AN OFFICE VISIT AND CONSISTS OF A SINGLE PAGE THAT CONTAINS A LIST OF COMMON SERVICES PROVIDED IN THE OFFICE. INITIATED WHEN THE PATIENT REGISTER AT THE FRONT DESK AND IS COMPLETED BY P |
| 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 ACCURATELY. |
| TISSUE REPORT/ PATHOLOGY REPORT | ASSISTS IN THE DIAGNOSIS AND TREATMENT OF PATIENTS BY DOCUMENTING THE ANALYSIS OF TISSUE REMOVED SURGICALLY ORDIAGNOSTICVALLY, OR THAT EXPELLED BY THE PATIENT |
| TRANSFER ORDER | PHYSICIAN ORDER DOCUMENTED TO TRANSFER A PATIENT FORM ONE FACILITY TO ANOTHER. |
| UNIFORM AMBULATORY CARE DATE SET (UACDS) | MINIMUM CORE DATA SET COLLECTED ON MEDICARE AND MIDICAID OUTPATIENTS. |
| UNIFORM HOSPITAL DISCHARGE DATA SET (UHDDS) | MINIMUM CORE DATA SET COLLECTED ON INDIVIDUAL HOSPITAL DISCHARGES FOR THE MEDICARE AND MEDICAID PROGRAMS; MUCH OF THIS INFORMATION IS LOCATED ON THE FACE SHEET. |
| UPCODING/MAXIMIZING CODES/DRG CREEP | DOCUMENTATION OF DIAGNOSES AND PROCEDURES THAT RESULT IN HIGHER PAYMENT FOR A FACILITY. |
| 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 PAPERBASED RECORD OR ENTERED INTO AND ELECTRONIC HEALT RECORD BY THE RESPONSIBLE PHYSICIAN. |
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destamay
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