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Med Rec #2

Med Rec

TermDefinition
Assembly Arranging the documents of the medical record 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 management d epartment is unable to manage the amount of work, such as transcript of dictation
Discharge Summary A report, dictated by a physician at the end of hospitalization, that details the diagnoses and treatment given
Optical Imaging System A computer system in which documents are converted into computer images that can be viewed simultaneously by multiple users
HIM 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 patient care
Quality Control Review of documents that have been scanned into an optical imaging system to insure that they are legible and have been indexed correctly
Scanning The process of converting paper documents into a computer image
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 HIM department, after, the patient has been discharged, that must be placed in the record
Medical Record A multiform document detailing the patient's diagnoses, diagnostic testing, and treatment giving 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
Created by: docdan
 

 



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