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The Patient Record

abbreviation list
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
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)
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
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
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