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Chapter 1

Being a Medical Records/ Health Information Clerk

TermDefinition
Assembly Arranging the documents of the medical record in a specified order after the discharge of the patient.
Authorization A signed consent of the patient or his or her representative to release confidential information.
Compromise care To make the patients care less effective.
Contract service A company hired to perform a function when the health information management department is unable to manage the amount of work, such as transcription of dictation.
Discharge summary A report, dictated by the physician at the end of hospitalization, that details the diagnoses and treatment given.
Health information management department The department, in a healthcare facility, responsible for maintaining security and confidentiality of patient records and for promoting responsible use of the records in a patient care.
Indexing Assigning a document to the correct patient, document type, and episode of care in an optical imaging system.
Loose documents Documents received by the health information management department, after the patient has been discharged, that must be places in the record.
Medical record A multiform document detailing the patient's diagnoses, diagnostic testing, and treatment given during an encounter with the hospital. Portions of the record may be computerized.
Medical transcription Interpretation and typing of reports dictated by physicians and other healthcare personnel.
Misfile To file a record or document in the wrong location.
Operative report A report dictated by the surgeon detailing the surgical procedure and findings.
Optical imaging system A computer system in which documents are converted to computer images that can be viewed simultaneously by multiple users.
Quality control Review of documents that have been scanned into an optical imaging system to ensure that they are legible and have been indexed correctly.
Scanning The process of converting a paper document into a computer image.
Created by: yunue03
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