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Chapter 11

The Health Record

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
Created by: mkuhlman209