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Med Rec #1
Med Rec
| Term | Definition |
|---|---|
| Abstracting | collection of data from the medical record for statistical and planning purposes |
| Analysis | Reviewing the medical record to determine that all required documentation is present including signatures and reports |
| Cancer Registry | A database of patients diagnosed with cancer |
| coding | Assignment of numbers or diagnoses and or procedures using the current edition of a coding classification system such as the International Classification of Diseases or Current Procedural Terminology |
| Deficiency slip | A document that identifies deficiencies in documentation |
| Healthcare Provider | An individual or facility, such as a hospital, that provides healthcare to a patient |
| JCAHO | Joint Commission on the Accreditation of the Healthcare Organizations |
| Litigation | Lawsuit |
| Medical Record Number | A unique number assigned to a medical record in order to identify it |
| Medical Transcription | Interpretation and typing of reports dictated by physicians and other healthcare personnel |
| Medicare | Federal insurance for patients over 65 or for the disabled |
| Performance Improvement | Evaluating the overall performance of a healthcare facility, from the environment to patient care, with the purpose of continuous improvement |
| periodical | A magazine or journal published at specific periods, for example, weekly, or monthly |
| Physician incomplete area | Area of health info management department where physicians come to patient care , with the purpose of continuous improvement |
| Physician Progress Note | handwritten or typed entries made by the physician regarding the patient's progress during hospitalization or other treatment |
| Risk Management | Addressing the risk to which patients, visitors, hospital staff, vendors, and others are expposed |
| Third Party | A person or entity, such as insurance company, other than tthe healthcare facility or patient |