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medical records
| Term | Definition |
|---|---|
| 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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