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medical records

TermDefinition
assembly arranging the documents of the medical records in a specified order after 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 patient's care less effective
contract service a company hired to perform a function when the health information managenment department is usable to manage the amount of work, such as transripition of dictation
discharge summary a report, dictated by physician at the end of hospitalization, that details the diagnoses and treatment given
health information management department the department, in healthcare facility, responsible for maintaing security and confidentiality of patients records and for promoting responsible use of the records in patients 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 placed in the records
medical transcription interpretation and typing of reports dictated by physician and other healthcare personnel
misflie 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 image that can be viewed simultaneously by multiple user
quality control review of documents that have been scanned into an optical imaging system to insure that they are legible and have been indexed correcty
scanning the process of converting a paper document into a computer image
medical records a multiform documents detailing the patients diagnose, diagnostic testing, and treatment given during an encounter with the hospital. portions of the record may be computerized
Created by: Smileyjelly
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