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Chapter 11
The Health Record
| Term | Definition |
|---|---|
| age of majority | age at which a person is recognized by law to be an adult; can vary by state. |
| alleviate | partly remove or correct; to relieve or lessen |
| alphabetic filing | any system that arranges names or topics according to the sequence of the letters in the alphabet |
| alphanumeric | filing systems made up of combinations of letters and numbers |
| augment | to increase in size or amount: to add to in order to improve or complete |
| caption | a heading, title, or subtitle under which records are filed |
| computerized provider/physician order entry (CPOE) | the process of entering medication orders or other provider instructions into the electronic health record (EHR) |
| continuity of care | continuation of care smoothly from on provider to another, so that the patient receives the most benefit and no interruption in care |
| culpability | Meriting condemnation, responsibility, or blame, especially as wrong or harmful |
| dictation | the act of manner of uttering words to be transcribed |
| direct filing system | a filing system in which materials can be located without consulting a additional source of reference |
| e-prescribing | electronic software to communicate with pharmacies and send prescribing information |
| electronic health record (EHR) | an electronic record of health-related information about a patient |
| electronic medical record (EMR) | an electronic record of health-related information about an individual; authorized clinicians and staff within a single healthcare organization |
| glgleaned | gathered bit by bit; (information or material) picked over in search of relevant material |
| indirect filing system | a filing system in which an intermediary source of reference must be consulted to locate specific files (a card file) |
| interoperability | the ability to work with other system |
| microfilm | a film with a photographic record of printed or other graphic matter on an reduced scale |
| numeric filing | the filing of records, correspondence, or cards by number |
| objective information | data obtained through physical examination, laboratory and diagnostic testing, and by measurable information |
| obliteration | the act of making undecipherable or imperceptible by obscuring or wearing away |
| outguide | a study cardboard or plastic file-sized card used to replace a folder temporarily removed from the filing space |
| parameters | any set of physical properties, the values of which determine characteristics or behavior |
| patient portal | a secure online web site that gives patients 24-hour access to personal health information using a username and password |
| personal health record (PHR) | an electronic record of health-related information about an individual that can be drawn from multiple sources but managed my the individual |
| pressboard | a strong, highly glazed composition board resembling vulcanized fiber; heavy card stock |
| provisional diagnosis | temporary diagnosis made before all test results have been received |
| purging | the process of moving active files to inactive status |
| puality control | an aggregate of activities designed to ensure adequate quality, especially in manufactured products or in the service industries |
| reasonable cause | circumstances that would make it unreasonable for the covered entity, despite the exercise of ordinary business care and prudence, to comply with the administrative simplification provision that was violated. |
| reasonable diligence | the business care and prudence expected from a person seeking to satisfy a legal requirement under similar circumstances |
| requisties | entities considered essential or necessary |
| retention schedule | method or plan for retaining or keeping health records and for their movement from active to inactive to closed filing |
| reverse chronological order | arranged in order so that the most recent item is on top and older items are filed further back |
| subjective information | data or information elicited from the patient, including the patient's feelings, perceptions, and concerns; obtained though interview or questions |
| subpoena duces tecum | a court order to produce documents or records |
| tickler file | a chronological file used as a reminder that something must be dealt with on a certain date |
| transcription | a written copy of something made either in longhand or by machine |
| vested | granted or endowed with a particular authority, right, or property; that a special interest in |
| willful neglest | conscious, internal failure or reckless indifference to the obligation to comply with the administrative simplification provision violated |
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mkuhlman209
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