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Med Rec #1

Med Rec

TermDefinition
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
Created by: docdan
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