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HDCS 1
The Patient Record
| Question | Answer |
|---|---|
| abbreviation list | |
| addendum | |
| administrative data | includes demographic, socioeconomic, and financial information |
| age of consent | |
| age of majority | |
| alternate care facilities | |
| alternative storage method | |
| amending the patient record | |
| archived records assessment (A) | |
| ASTM E 1762-Standard Guide for Authentication of Healthcare Information | |
| audit trail | |
| authentication | an entry is signed by the author |
| auto-authentication | Involves a provider authenticating a dictated report prior to its transcription. |
| automated record system | |
| character | |
| chart deficiencies | |
| chronological date order | |
| clinical data | all patient health information obtained throughout the treatment and care of the patient |
| clinical data repository | |
| COmputer STored Ambulatory Record (COSTAR) | |
| countersignature | |
| cryptography | |
| database | |
| deficiency slip | |
| delinquent record | |
| delinquent record rate | |
| demographic data | is patient identification information collected accord¬ing to facility policy and includes the patient's name and other information, such as date of birth, place of birth, mother's maiden name, social security number |
| diagnostic/management plans | |
| digital archive | is a storage solution that consolidates electronic records |
| digital signature | |
| document imaging | |
| electronic health record (EHR) | |
| electronic medical record (EMR) | |
| electronic signature | |
| field | |
| file | |
| hospital ambulatory care record | |
| hospital inpatient record | the care and treatment received by a patient admitted to the hospital |
| hospital outpatient record | documents services re¬ceived by a patient who has not been admitted to the hospital overnight and includes ancillary services (e.g., lab tests, X-rays, and so on), emergency depart¬ment services, and outpatient (or ambulatory) surgery |
| inactive records | |
| incident report | |
| independent database | contains clinical information created by researchers, typically in academic medical centers |
| indexed | which means it is identified according to a unique identification number |
| information capture | the process of recording rep¬resentations of human thought, perceptions, or ac¬tions in documenting patient care, as well as device-generated information that is gathered and/or computed about a patient as part of health care |
| initial plan | |
| integrated record | |
| jukeboxes | store large numbers of optical disks, resulting in huge storage capabilities |
| longitudinal patient record | |
| magnetic degaussing | |
| manual record | |
| mHealth | |
| microfilm | |
| nursing assessment | |
| objective (0) | observations about the patient, such as physical findings or lab or X-ray results |
| off-site storage | |
| optical disk imaging | |
| patient education plans | |
| patient record | is the business record for a patient encounter |
| patient's representative | |
| physician office record | |
| plan (P) | diagnostic, therapeutic, and educational plans to resolve the problems |
| potentially compensable event (PCE) | |
| preadmission testing (PAT) | |
| primary sources | |
| problem list | |
| problem oriented medical record (POMR) | |
| problem oriented record (POR) | |
| provisional diagnosis | |
| public key | |
| purge record | remove inactive records from the file system |
| record destruction methods | |
| record linkage | |
| record retention schedule | |
| remote storage | |
| report generation | |
| retention period | |
| reverse chronological date order | |
| scanner | used to capture paper record images onto the storage media |
| secondary sources | |
| sectionalized record | |
| shadow record | is a paper record that contains copies of original records and is maintained separately from the primary record |
| signature legend | |
| signature stamp | |
| solo practitioner | |
| source oriented record (SOR) | |
| statute of limitations | |
| subjective (S) | patient's statement about how they feel, including symptomatic information |
| telephone order (T.O.) | |
| therapeutic plans | |
| transfer note | |
| voice order (V.O.) |
Created by:
lisakendall
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