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ch.2
Question | Answer |
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Abstracting | Collection of data from the medical record for statistical and planning purposes. |
Analysis | Reviewing the medical record to determine that all required documentation is present including signatures and reports. |
Cancer registry | A database of patients diagnosed with cancer. |
Coding | Assignment of numbers to diagnose and/or procedures using the current edition of a coding or classification system such as the international classification of diseases (ICD) or current procedural terminology. |
Deficiency slip | A document that identifies deficiencies in documentation. |
Healthcare provider | An individual or facility, such as a hospital, that provides healthcare to a patient. |
JCAHO | Joint commission on the accreditation of healthcare organizations. |
Litigation | Lawsuit |
Medical record number | A unique number assigned to a medical record in order to identify it. |
medical transcription | Interpretation and typing of reports dictated by physicians and other healthcare personnel |
medicare | Federal insurance for patients over 65 or for the disabled. |
Performance improvement | Evaluating the overall performance of a healthcare facility, from the environment to patient care, with the purpose of continuous improvement. |
Periodical | A magazine or journal published at specified periods, for example, weekly or monthly. |
Physician progress note | handwritten or typed entries made by the physician regarding the patient's progress during hospitalization or other treatment. |
Risk management | Addressing the risk to which patients,visitors,hospital staff,medical staff, vendors, and others are exposed. |
third party | a person or entity, such as an insurance company, other than the healthcare facility or patient. |