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HIT 114 chapter 6

hit 114 chapter 6

the diagnosis determined after evaluation and documented by the attending physician upon the discharge of the patient from the facility. final diagnosis
consists of patient's name and some other piece of identifying information such as medical record number or date of birth. Patient identification
An assumed name. (E.G. Celebrities may do this to keep out of the press) Alias
Plastic card containing patient identification; used to imprint information on each report in the patient record. Addressograph machine
including the name of the facility mailing address & a telephone# must also be included on each report in the record so that an individ or health care facility on receipt of copies of the record can contact the facility for clarification of record content facility address
contain patient id or demographic, financial data, & clinical information. Usually filed as the first page of the patient record because it's frequently referenced. face sheet (or admission/discharge record)
working, tentative, admission, & preliminary diagnosis obtained from the attending physician; it is the diagnosis upon which impatient care is a initially based. admitting diagnosis or provisional diagnosis
the min. core data set collected on individual hospital discharges for the Medicare and Medicaid programs, & much of this information is located on the face sheet. Uniform Hospital Discharge Data Set (UHDDS)
condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care. Principal diagnosis
Additional conditions for which the patient received treatment and/or impacted the inpatient care Secondary diagnoses
pre-exisiting condition that will, because of it's presence with a specific principal diagnosis, cause an increase in the patient's length of stay by at least one day in 75% of the cases. Comorbidities
add. diagnoses that describe conditions arising after the beginning of hospital observation&treatment&that modify the course of the patient's illness or the medical care required they prolong the patient's length of stay by at least 1day in 75% ofthecases complications
procedure performed for definitive or therapeutic reasons, rather than diagnostic purposes, or to treat complication, or that procedure which is most closely related to the principal diagnosis. principal procedure
additional procedures performed during inpatient admission. secondary procedures
verified diagnoses and procedures documented & coded at discharge. attestation statement
Documentation of diagnoses & procedures that result in higher payment for a facility; also called maximizing or DRG creep upcoding
signed by the patient to document that the patient has been notified of his or her right to have an advance directive advance directive notification form
a legal document in which patients provide instructions as to how they want to be treated in the event they become very ill and there is no reasonable hope for recovery. advance directive
the process of advising a patient about treatment options &, depending on state laws, the provider may be obligated to disclose a patient's diagnosis, proposed treatment/surgery reason for the treatment/surgery, possible complications... informed consent
Legal document (recognized by New York State) in which the patient chooses another person to make treatment decisions in the event the patient becomes incapable of making these decisions. ALSO called durable power of Attorney Health care proxy
a generalized consent that documents a patient's consent to receive medical treatment at the facility. Also called conditions of admission consent to admission
records items patients being with them to the hospital. Must be signed by hospital staff and patient. Must be signed so patient can claim afterwards. patient property form
record of birth information about the newborns patient & the parents, & it identifies medical information regarding the pregnancy & birth of the newborn. certificate of birth or birth certificate
contains a record of information regarding the decedent, his or her family cause of death, and the disposition of the body. Certificate of death certificate
includes all health care information obtained about a patient's care and treatment, which is documented on numerous forms in the patient record. Clinical data
documents the evaluation and treatment of patients seen in the facility's emergency department (ED) for immediate attention of urgent medical conditions or traumatic injuries. Emergency record
generated by emergency medical technicians (EMTs)to document clinical information such as vital signs, level of consciousness, appearance of the patients, & so on. Ambulance report
Prevents facilities licensed to provide emergency services from transferring patients who are unable to pay to other institutions, & it requires that a patient's condition must be stabilized prior to transfer (unless patient requests transfer). Anti-dumping legislation (Emergency Medical Treatment and Labor Act, EMTALA)
provides information for continuity of care and facilities medical staff committee review; it can also be used to respond to requests from authorized individuals or agencies. Also called Clinical resumes discharge summary
An uncomplicated hospital stay of less than 48 hours. Short Stay
documents the patient's chief complaint, history of present illness (HPI), past/family/social history (PFSH), and review of systems (ROS). History
Patient's description of medical condition, stated in the patient's own words. Chief Complaint (CC)
Chronological description of patient's present condition from time of onset to present.should include location, quality, severity, duration of the condition, and associated signs and symptoms. History of patient's illness (HPI)
Summary of past illnesses, operations, injuries, treatments, and known allergies. Past History
A review of the medical events in the patient's family, including diseases that may be hereditary or present a risk to the patient. family history
An age-appropriate review of past and current activities such as daily routine, dietary habits, exercise routine, martial status, occupation, sleeping patterns, smoking, use of alcohol and other drugs, sexual activities, and so on. Social History
Inventory by systems to document subjective symptoms stated by patient.Provides an opportunity to gather information that the patient may have forgotten to mention or that may have seemed unimportant.Ex: Respiratory: The patient denies shortness of breath Reviews of Systems (ROS)
documents a patient's history of present illness & any pertinent changes & physical findings that occurred since a previous inpatient admission if the patient is readmitted within 30 days after discharge for the same condition. interval history
Physicians performs a ________, which is an assessment of the patient's body systems to assist in determining a diagnosis, documenting a provisional diagnosis, & which may include differential diagnoses. Physical examination
indicates that several diagnoses are being considered as possible. differential diagnoses
the provision of health care services by a consulting physician whose opinion or advice requested by another physician. Consultation
is documented by the consultant and includes the consultant's opinion and findings based on a physical to provide evaluation &, possible, treatment of a patient. consultation report
directs the diagnostic and therapeutic patient care activities (e.g. medications and dosages, frequency of dressing changes, and so on).should be: clear & complete, Legible, dated and time, authenticated by the responsible physician. Physician orders (doctors orders)
uses a computer network to communicate physician (& other qualified provider) instructions for patient care to the health care facility staff & the other departments. Computerized physicians order entry (CPOE)
contain statements related to the course of the patient's illness, response to treatment, & status at discharge. Progress notes
all progress notes documented by physicians, nurses, physical therapist, occupational therapist, & other professional staff members are organized in the same section of the record. integrated progress notes
The final physicians order documented to release a patient from a facility. Discharge order
Patients who sign themselves out of a facility do so ___________, they sign a release from responsibility for discharge. Against medical advice (AMA)
Physician's orders preapproved by the medical staff, which are preprinted and placed on a patient's record. routine order
Physician orders preapproved by the medical staff (preprinted and placed on the patient's record), which direct the continual administration of specific activities for a specific period of time as a part of diagnostic or therapeutic care. Standing order
AS a patient safety mechanism, state law mandates, & in the absence of state law facilities decide, for which circumstances preapproved standing physician orders are automatically stopped, requiring, the physician to document a new order . Stop order or Automatic stop order
A verbal order dictated via telephone to an authorized facility staff member. Telephone Order (T.O.)
requires the authorized staff member to read back & verify what the physician dictated to ensure that the order is entered accurately. telephone order call back policy
to document that the telephone order call back policy was followed, the staff member enter the abbreviation _____ below the telephone order (and then signs the order). RAV (read and verified)
A physician order documented to transfer a patient from one facility to another. Orders are documented to an authorized facility staff member (e.g., RN, pharmacist, etc.,) because the responsible physician is unable to personally document the order. Transfer Order Verbal Order
A verbal order dictated to an authorized facility staff member by the responsible physician who also happens to be present. Verbal Order (V.O.)
Orders that are handwritten in a paper-based record or enter into an electronic health record by the responsible physician. Written order
Progress noted documented by the attending physician at the time of patient admission, which includes: Reason for admission, including description of patient's condition, Brief HPI, Patient care plan, Method/mode of arrival (eg ambulance), etc,. Admission Note
Daily progress notes documented by the responsible physicians, which include: Patient's condition, findings on examination, abnormal test findings, etc,. Follow-up progress notes
final progress note documented by the attending physicians, which includes: patient's discharge destination (eg Home), discharge medication, activity level allowed, follow-up plan (EG office appointment) Discharge notes
Progress note documented by a case manager, which outlines a discharge plan that includes case management/social services & patient education. case management note
Progress notes documented by various rehabilitation therapist toward established therapy goals. Rehabilitation Therapy Progress Note
Progress note documented by the dietician (or authorized designee), which includes: Patient's dietary needs, any dietary observations made by staff Dietary Progress notes
R.T.P. notes documented by respiratory therapists include therapy administered, machines used, medication(s), added to machines, type of therapy, dates/times of admin., specifications of the prescription, & reassessments of duration/ Respiratory Therapy Progress note (R.T.P.)
A progress note documented by any individual qualified to administer anesthesia (not just the individual who administered anesthesia to the patient) prior to the induction of anesthesia. Preanesthesia Evaluation Note
A progress note documented by the surgeon prior to surgery, which summarizes the patient's condition and documents a preoperative diagnosis. Preoperative Note
A progress note documented by the surgeon after surgery, which documents the patient's vital signs & level of consciousness; any medications, including intravenous fluids, administered blood, blood products,& blood components. Postoperative
required when a patient receives an anesthetic other than a local anesthetic, to document agents and other activities, related to the surgical episode. Anesthesia record
describes gross findings, organ examined (visually or palpated), & techniques associated with the performance of surgery. It is to be dictated or handwritten immediately following the operation & authenticated by the responsible surgeon. Operative record
assists in the diagnosis & treatment of patients by documenting the analysis of tissue removed surgically or diagnostically, or that was expelled by the patient. Also called tissue report. Pathology report
Created by: crh9008