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Med Rec #2
Med Rec
| Term | Definition |
|---|---|
| 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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