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Healthcare Med Rec 1

Medical Terminology

TermDefinition
medical record the lifetime record of a patient’s health, health problems, and medical care at a particular institution
medical history a patient’s health history, including information such as allergies, medications being taken, past medical history (PMH, e.g., prior illnesses and surgeries), social history (SH, e.g., occupation and habits), and family history (FH)
medical encounter a single patient-provider visit, during which the patient’s chief complaint (CC) and the history of the present illness (HPI) are discussed, a physical examination (PE) is performed, and a diagnosis (DX) and treatment (TX) plan are made
personal health record a medical record that is maintained by the patient for personal benefit
American Health Information Management Association (AHIMA) not-for-profit professional organization serving the educational, credentialing, networking, and advocacy needs of health information management (HIM) professionals
data quality management model an AHIMA concept that standardizes data storage, maintenance, and organization according to ten quality characteristics
data quality characteristics the ten AHIMA data quality characteristics that require data to be accurate, accessible, comprehensive, consistent, current, defined, granular, precise, relevant, and timely
history refers to a patient's past medical history, as well as the history of the present illness
exam includes both a physician's physical examination of a patient, as well as any test results
medical decision making component of the health record that substantiates the care provided, supports reimbursement for each procedure, and serves as a legal document that validates the treatment provided for each diagnosis
Created by: rleroux