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Vocabulary 2

Vocab 2

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 number to diagnose and/or procedures using the current edition of coding or classifications system such as the international classification of disease ( ICD ) or current procedural terminology
Defiency slip a document that identifies deficiencies in documentation.
Healthcare provider an individual or facility such as a hospital that provides healthcare to patient
JCAHO Joint commission on the accreditation of health organizations
litigation lawsuit
Medical transcription interpretation and typing of reports dictated by physicians and other healthcare personnel
medicare federal insurance for patients over 65 or for disabled
Performance improvement evaluating the overall performance of a healthcare facility from the environment to patient care with the purpose of continues improvement
periodical a magazine or journal published at specified periods for example weekly or monthly
physician incomplete area are of the health information management where physicians come to work on incomplete records
Physician progress note handwritten or typed entries made by physicians regarding the patients 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 healthcare facility or patient
Created by: airamgalvan