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Stack #425700
| Question | Answer |
|---|---|
| Clinical data | Includes all patient health information obtained throughout the treatment and care of the patient. |
| Administrative data | Includes demographic, socioeconomic, and financial information. |
| Patient Record | Serves as the business record for a patient encounter, contains documentation of all health care services provided to a patient, record treatment results. |
| Demographic data | 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, and so on. |
| 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 gathered and/or computed about a patient as part of health care. |
| Report generation | It is the process of analyzing, organizing, and presenting recorded patient information for authentication and inclusion in the patient's health care record. |
| off-site storage | Electronic or paper patient data is stored someplace other than the treating facility. |
| Hospital Outpatient Record | Documents services received 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 department services, and outpatient (or ambulatory) surgery. |
| Physician Office Record | Patient health care services received in a physician's office are documented in the physician office record. |
| Countersignatures | A countersignature is a form of authentication by an individual in addition to the signature by the original author of an entry. |
| Telephone order (T.O.) | A verbal order taken over the telephone by a qualified professional (e.g., registered nurse) from a physician. |
| Voice order (V.O.) | Physician dictates an order in the presence of a responsible person, is no longer accepted as standard practice by health care facilities. A V.O. is documented in emergencies only. |
| Electronic Signatures | An electronic signature is a generic term that refers to the various methods an electronic document can be authenticated. |
| ASTM E 1762-Standard Guide for Authentication of Healthcare Information. | The American Society for Testing and Materials (ASTM) developed ASTM E 1762-Standard Guide for Authentication of Healthcare Information, which is intended to complement standards developed by other organizations (e.g., Health Level 7, or HL7) and define: |
| Signature Stamps | A rubber stamp made to be used as a signature instead of hand writing |
| Abbreviation list | The facility should maintain an official abbreviation list, which includes medical staff-approved abbreviations, acronyms, and symbols (and their meanings) that can be documented in patient records. |
| Amending the Patient Record | Only author may amend information by drawing a line through incorrect info, date time and sign correction, reason for correction and the correct information. |
| Audit trail | Most electronic health record systems will create a list of all changes made to patient documentation in the form of an audit trail, which is a technical control created by an electronic health record system. |
| Auto-authentication | A provider authenticates a dictated report prior to its transcription. This practice is not consistent with proper authentication procedures because providers must authenticate the document after it was transcribed |
| Authentication | All patient record entries require authentication, which means an entry is signed by the author. |
| Delinquent records | The JCAHO requires patient records to be completed 30 days after patient is discharged, at which time they become delinquent records |
| Delinquent Record rate | To calculate the delinquent record rate, divide the total number of delinquent records by the number of discharges in the period. |
| Addendum | The purpose of the addendum is to provide additional information, not to change documentation, and the addendum should be documented as soon after the original entry as possible. |
| Preadmission testing (PAT) | Incorporates patient registration, testing, and other services into one visit prior to inpatient admission (or scheduled outpatient surgery), and the results are incorporated into the patient's record. |
| Provisional diagnosis | (or working, tentative, admission, preliminary diagnosis), which is obtained from the attending physician and is the diagnosis upon which patient care is based. |
| Patient's representative | The person who has legal responsibility for the patient |
| Nursing assessment | Documents the patient's history, current medications, and vital signs on a variety of nursing forms, including nurses' notes, graphic charts, and so on. |
| Reverse chronological date order | Means that the most current document is filed first in a section of the record. |
| Solo practitioner | A physician who practices alone. |
| Manual record | A paper record |
| Primary sources | Records that document patient care provided by health care professionals are considered primary sources of patient information. |
| Secondary sources | data abstracted (selected) from primary sources of patient information |
| Incident report | Collects information about a potentially compensable event (PCE), which is an accident or medical error that results in personal injury or loss of property. |
| Potentially compensable event (PCE) | An accident or medical error that results in personal injury or loss of property. I |
| Source Oriented Record (SOR) | Maintains reports according to source of documentation. This means that all documents generated by the nursing staff are located in a nursing section of the record, radiology reports in a radiology section, and physician-generated documents. |
| Problem Oriented Record (FOR) | The problem oriented record is a more systematic method of documentation, which consists of four components:Database,Problem list,Initial plan,Progress notes. |
| Problem oriented medical record (POMR) | Lawrence Weed developed the problem oriented medical record (POMR), now called the problem oriented record (POR), in the 1960s to improve organization of the patient record. |
| Integrated Record | The integrated record format usually arranges reports in strict chronological date order This format allows for observation of how the patient is progressing according to tests results and how the patient responds to treatment based on test results. |
| Automated Record Systems | Will ultimately replace paper-based records to provide timely access to health information for health surveillance, resource planning, and health care delivery. |
| Electronic health record (EHR) | A computer-based patient record (CPR),which is a collection of patient information documented by a number of providers at different facilities regarding one patient. |
| Electronic medical record (EMR) | Is created on a computer using a keyboard, mouse, optical pen device, voice recognition system, scanner, or touch screen. |
| Optical disk imaging (or document imaging) | Provides an alternative to traditional microfilm or remote storage systems because patient records are converted to an electronic image and saved on storage media (e.g., optical disks). |
| Scanner | It is used to capture paper record images onto the storage media (e.g., optical disk). It allows for rapid automated retrieval of records. |
| Indexed | It is identified according to a unique identification number (e.g., patient record number). |
| Jukeboxes | Stores large numbers of optical disks, resulting in huge storage capabilities. |
| The COmputer STored Ambulatory Record (COSTAR | System is an outpatient EHR created at Massachusetts General Hospital in the 1960s with the goal of improving the availability and organization of outpatient records. |
| Longitudinal patient record (or record linkage) | 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. |
| Inactive records | Records placed in storage and rarely accessed are called archived records or Inactive records. |
| Retention period | facility should develop policies that indicate the length of time a facility will maintain an archived record. |
| Digital archive | Is a storage solution that consolidates electronic records (e.g., audio, emails, scanned documents and images, video, and so on) on a computer server for management and retrieval. |
| Shadow record | is a paper record that contains copies of original records and is maintained separately from the primary record. |
| Independent database | Contains clinical information created by researchers, typically in academic medical centers. |
| Record Retention Schedule | This schedule outlines the information that will be maintained, the time period for retention, and the manner in which information will be stored. |
| Statute of limitations | Is the time period during which a person may bring forth a lawsuit. |
| Age of consent (or age of majority), | means facilities must retain records for a time period (e.g., 18 years) in addition to the retention law. |
| Alternative Storage Methods | Off-site storage, microfilm, or optical imaging. |
| Microfilm | photographic process that records the original paper record on film, with the film image appearing similar to a photograph negative. |
| Record Destruction Methods | Paper-based records should be destroyed in a manner consistent with established policies and procedures, after the legal retention period (e.g., federal, state, and so on), and after microfilming or using optical imaging to store records. |
| Deficiency slip | To facilitate completion of record deficiencies, a deficiency slip is completed by the analysis clerk and attached to the patient record. |
| alternate care facilities | that provide behavioral health, home health, hospice, outpatient, skilled nursing, and other forms of care |
| Hospital inpatient record | documents the care and treatment received by a patient admitted to the hospital. |
| 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 |
| SNOMED-CT | Systemized Nomenclature of Medicine, Clinical Terms |
| Hospital ambulatory care record or hospital outpatient record | documents services received 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 department services, and outpatient (or ambulatory) surgery. |
| Chronological date order | Oldest files in the front and newest file in the back. |
| mHealth | the use of wireless technology to enable health care professionals to make better-quality decisions while reducing the cost of care and improving convenience to caregivers. |
| Problem list | acts as a table of contents for the patient record because it is filed at the beginning of the record and contains a list of the patient's problems. |
| Initial plan | describes actions that will be taken to learn more about the patient's condition and to treat and educate the patient, |
| Diagnostic/management plans | plans to learn more about the patient's condition and the management of the conditions |
| Patient education plans | plans to educate the patient about conditions for which the patient is being treated |
| Subjective (S) | patient's statement about how they feel, including symptomatic information (e.g., headache) |
| Objective (O) | observations about the patient, such as physical findings or lab or X-ray results (e.g., chest X-ray negative) |
| Assessment (A) | judgment, opinion, or evaluation made by the health care provider (e.g., acute migraine) |
| Plan (P) | diagnostic, therapeutic, and educational plans to resolve the problems (e.g., patient to take Tylenol as needed for pain) |
| Digital signature | is created using public key cryptography to authenticate a document or message. |
| Public Key | Public key 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 |
| Signature legend | a document maintained by the health information department to identify the author by full signature when initials are used to authenticate entries. |
| Database | minimum set of data to be collected on every patient, such as chief complaint; present conditions and diagnoses; social data; past, personal, medical, and social history; review of systems; physical examination; and baseline laboratory data. |
| Clinical data repository | allows for the collection of all clinical data in one centralized database, and provides easy access to data in electronic or printed form to the patient's clinical history. |
| Archived records | Records placed in storage and rarely accessed |
| Purge record | (remove inactive records from the file system) and convert paper-based records to microfilm or optical disk. |
| Remote Storage | Off-site storage (or remote storage) is used to store records at a location separate from the facility. |
| Magnetic degaussing | alters magnetic fields on a computer medium |
| Chart Deficiencies | Information missing from the medical chart. |
| Character | A letter, number or symbol |
| File | A place to store data. |
| Field | A designated area on a form. |
| Sectionalized record | source oriented record (SOR) maintains reports according to source of documentation. This means that all documents generated by the nursing staff are located in a nursing section and so on. |
| Transfer note | A summary of the patients illness, history and treatment for the physician they are transferring to. |
Created by:
hnireland