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medical records
chapter 1 vocab
| Term | Definition |
|---|---|
| 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 mangagment department after the patient has been discharged that must be placed in the record |
| medical record | A multi-form document detailing the patients diagnosis diagnostic testing and treatment given during an encounter with the hospital portions of the record may be computerized |
| medical transcription | interpretation and typing of records dictated by physicians and other healthcare personnel |
| misfile | to file a record or document in the wrong location |
| scanning | the process of converting a paper document into a computer image |
| operative report | a report dictated by the surgeon detailing the surgical procedure and findings |
| assembly | Arranging the documents of the medical record in a specific order after discharge of the patient |
| authorization | a signed consent of the patient or his or her representative to release confidential information |
| compromised care | to make the patients care less affective |
| 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 a physician at the end of hospitalization that details the diagnosis and treatment given |
| health information management department | the department in a health care facility responsible for maintaining security and confidentiality of the patients records for promoting responsible use of the record in the patients care |
| 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 insure that they are legible and have been indexed correctly |
Created by:
amywap
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