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Healthcare Med Rec 1
Medical Terminology
Term | Definition |
---|---|
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 |