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Patient Record

Patient Record Vocabulary

abbreviation list medical staff-approved abbreviations, acronyms, and symbols
addendum amending an entry to the medical record to clarify or add additional information
administrative data includes demographic, socioeconomic and financial information
administrative terminologies primarily designed for statistical and epidemiological reports, reimbursement for healthcare services analysis of managerial processes and other secondary data aggregation and anlysis purposes; output systems.
alternate care facilities providing behavioral health, home health, hospice, outpatient, skilled nursing, and other forms of care; also serve as a documentation source for patient care information
alternative storage method such as off-site storage, microfilm or optical imaging
amending patient record only the author of the original entry, draw line through entry, date, time and sign
archived records records that are in storage and are rarely used
assessment judgement, opinion, or evaluation made by the health care provider
ASTM E 1762 Standard Guide for Authentication of Healthcare Information
audit trail a list of all changes made to patient documentation, containing date, time and user who performed the transaction
authentication an entry signed by the author
auto-authentication involves authenticating a dictated report prior to its transcription, no consisten with proper authentication because it is done after transcription
automated record system replaces paper-based records to provide timely access to health information
character an electronic and/or digital letter, number or symbol
chart deficiencies incomplete or delinquent charts, missing reports and other documentation or signatures
chronological date order filing of patient information in order of first visit to completion of treatment
classification system that groups together similar diseases and procedures and organizes related entities for easy retrieval
clinical data includes all patient health information obtained throughout the treatment and care of patient
clinical data repository allows for the collection of all clinical data in one centralized database, to provide easy access to data in electronic or printed form
coding assigning of widely identified series of numbers or letters, for easy identification of illness, medical treatment or procedure
computer-based patient record (CPR) same as electronic health record (EHR)
COSTAR Computer Stored Ambulatory Record - outpatient electronic health records, created as Massachusetts General Hospital in 1960's with the goal of improving the availability and organization of outpatient records
conditions of participation (COP) the report of physical exam must be placed in the patient record within 48 hours after admission
controlled clinical reference terminologies clinical info that is captured in an electronic health record during the course of patient care, allowing the creation of detailed electronic clinical health records thru direct entry at the point of care
countersignature form of authentication by an individual in addition tot he signature by the original author of an entry; required when documenting a telephone order taken from a physician
cryptography uses an algorithm of two keys, one for creating the digital signature by transforming data into a seemingly unintelligible form and the other to verify a digital signature and return the message to its original form
database contains a minimum set of data to be collected on very patient, serves as an overview of patient information
deficiency slip is completed by the analysis clerk and is attached to the patient record to facilitate completion of record deficiencies
delinquent record incomplete records are considered delinquent after 30 days, privilieges may be suspended until records are completed
delinquent record rate divide the total number of delinquent records by the number of discharges in the period
demographic data includes patient's name, date of birth, place of birth, mother's maiden name, social security number, etc.
diagnostic/management plan plans to learn more about the patient's condition and the management of the condition
digital archive a storage solution that consolidates electronic records on a computer server for management and retrieval
digital signature created using public key cryptography to authenticate a document or message
document imaging same as optical disk imaging
electronic health record (EHR) medical records permanently stored on a disk, records are viewed on a monitor or as printout; famility designates their legal medical record as either electronic or paper-based; same as CPR
electronic medical record (EMR) created on a computer using a keybaord, mouse, optical pen device, voice recognitions system, scanner or touch screen
electronic signature term that refers to the various methods an electronic document can be authenticated, including name at the end of an email, image of handwritten signature, secret PIN, fingerprint or retinal scan or digital signature
field a group of characters fors a field, a collection of related fields form a record
file a collection of related records
heuristics rules of thumb
hospital ambulatory care record services received by a patient who has not been admitted to the hopstial, and includes ancillary services, emergency department services, and outpatient surgery; ambulatory = outpatient
hospital inpatient record documents the care and treatment received by a patient admitted to the hospital
hospital outpatient record documents the care and treatment received by a patient who is not admitted for treatment
ICD-03 International Statistical Classification of Diseases for Oncology, Third Edition
inactive records records placed in storage and rarely accessed; same as archived records
incident record generated for patient and visitor accidents, providing a summary of an event for documentation purposes
independent database contains clinical information created by researchers, typically in academic medical centers
indexed indentified according to a unique identification number, such as patient record number
information capture the process of recording representations of human thought, perceptions, or actions in documenting patient care, as well as device-generated information that is gathers, and/or computed about a patient as part of health care
initial plan how the strategy for management of the patient's care is outlined
integrated record arranges reports in strict chonological date order, or revers date order; allows for observation of how the patient is progressing and responds to treatment
interface used in electronic health record systems for presentation to end users, to facilitate electronic data collection at the point of care
jukeboxes store large numbers of optical disks, resulting in huge storeage capabilities
LOINC Logical Observation Identifiers Names and Codes
longitudinal patient record contains records from different episodes of care, providers and facilities that are linked to form a view, over time, of a patient's health care encounters (same as record linkage)
magnetic degaussing alters magnetic fields on a computer medium
manual record maintaining patient records in a paper format
mapping the process of linking content from one terminology to another or to a classification
MHealth refers to the use of wireless technology to enable health care professionals to make better quality decisions, while reduing cost of care and improving convenience to caregivers; provider can quickly update physician orders
microfilm photographic process that records the original paper record to film, with the film image appearing similar to a photo negative
MIR Medical Record Institute
NCVHS National Committee on Vital and health Statistics
nomenclature a recognized system of names
nursing assessment documents the patient's history, current medications, and vital signs on a varity of nursing forms in the nursing unit, including nurses' notes, graphic charts, etc
objective observations abou the patient, such as physical findings or lab/xray results
off-site storage used to store records at a location separate from the facility
optical disk imaging same as document imaging; provides an alterntive to traditional microfilm or remote storage systems, patient records are converted to an electronic image and save on storage media, using laser technology to creat the image
patient education plan ancillary services provided by a a health care facility
patient record the business record for a patient encounter, containing documentation of all health care services provided to a patient
patient's representative the person who has legal responsibility for the patient, signs admission consent form to document consent to treatment, as well as other legal forms
physician office record patient health care services received in a physician office, including admin and clinical data
plan diagnostic, therapeutic and eduational plans to resolve the patient's problems
potentially compensable event (PCE) an accident or medical error that results in personal injury or loss of property
preadmission testing (PAT) incorporates patient registration, testing and other services into one visit prior to inpatient and outpatient surgery; reduces length of stay
primary sources records that document patient care provided by health care professionals
problem list symptoms, specific diagnoses, abnormal findings, physiologic findings in the problem oriented record; continuous, as new findings are added
problem oriented medical record (POMR) now known as FOR
problem oriented record (FOR) systematic method of documentation which consists of four componenets; database, problem list, initial plan and progress notes
progress notes documented as subjective, objective, assessment and plan
provisional diagnosis is obtained from the attending physician and is the diagnosis upon which patient care is based
public key public key cryptography uses algorithm of two keys, one for creating the digital signature and the other to verify a digital signature, and returning the message to it's original form
purge record removing an inactive record from the file system
record destruction methods designated destruction rules for the various types of records, implemented after the end of the record retention period
record linkage same as longitudinal patient record
record retention schedule a set time period for the various types of records
reference terminology a set of concepts and relationships that provide a common reference point for comparisons and aggregation of data about the entire health care process
remote storage storage of records offsite, at another facility
report generation the creation of a healthcare document, consisting of recorded patient information, for analyzing, organizing and presenting for authentication
retention period the length of time a facility will maintain an archived record
reverse chronological date order the most current document is filed first, in the patient record
scanner used to capture paper record images onto the storage media, allowing for rapid automated retrieval of records
secondary sources contain data abstracted from primary sources of patient information
sectionalized record the record is subdivided into sections
shadow record a paper record that contains copies of origianl records and is maintained separately from the primary record
signature legend a document maintianed by the health information department to identify the author by full signature, when initials are used to authenticate entries
signature stamp provider must sign a statement aurthorizing use of this type of signature, in place of actual physician signature
SNOMED-CT Systemized Nomenclature of Medicine, Clinical Terms; controlled clinical reference terminology with comprehensive coverage of diseases, clinical findings, etiologies, procedures, living organisms and outcomes
solo practitioner a physician who practices alone
source oriented record (SOR) the patient record is divided into sections, according to type of treatment; nursing notes are kept in the nursing section, physician orders, progress notes, etc in the medical section, xray results in the radiology section, etc
statute of limitations the time period during which a person may bring forth a lawsuit; when that time period is up, there is no legal right to sue
subjective patient's statement about how they feel, including symptomatic information
telephone order a verbal order taken over the phone by a qualified professional from a physician
terminology a set of terms representing the system of concepts of a particular subject field
therapeutic plans specific medications, goals, procedures, therapies, and treatments used to treat the patient
transfer note documents transfer of a patient to another facility, summarizes reason for admission and transfer, current diagnoses and medical information
UMLS Unified Medical Language System
universal chart order organize reports in the same order for both inpatient and discharged patient records
voice order the physician dictates an order in the presence of a responsible person, no longer accepted as standard practice by health care facilities; voice orders are documented in emergencies only
Created by: erosok
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