Question | Answer |
alternative care facilities | provide behavioral health, home health, hospice, outpatient,skilled nursing and other formas of care also serve as documentation patient care information. |
patient record | a business record for a patient encounter, contains dicumentation of all health services. |
demographic data | patient identifiction information collected according to facility policy and includes patient's name and other info such as date of birth, birthplace, mother's name etc... |
Information capture | process of recording representations of human thought, preceptions, or actions in documentating patient care, as well as device generated information that is gathered and computed about a patient as part of health care. |
report generation | construction of a healthcare document, consists of formatting and structuring of captured information |
continuity of care | the primary purpose of the patient record. |
hospital impatient record | documents the care and treatment received by a patient admitted to the hospital |
administrative data | includes demograhphic, socioeconomic, and financial data |
clinical data | includes all info about the patients health and treatment throught the care process |
hospital outpatient record | documents services received by a patient who has not been admitted into the hospital |
authentication | the entry must be signed by the author |
countersignature | a form of authentication by an individual in addition to the signature of the orginal author |
telephone order | is a verbal order over the phone by a qualified professional from aphysician |
voice order | the physician dictates an order in the presence of a responsible person. this practce is no longer used. |
signature legend | a complete signature that matches initial that are on a record |
electronic signatures | is a generic term that refers to the variuos methods of electronic documents that are authenticated electronically. |
digital signature | is created using a public key cryptograophy to authtenticate a dicument |
public key cryptography | uses an algothrium of 2 keys , one for creating the digital signature by transforming data and other to verify the key. |
signature stamps | a stamp that has an authorized signature on it |
abbreviation list | includes a list of medical abbreviation that are approved by staff |
deliquent records | records that aren't processed before the 30 days mark after a patient is discharged |
amending the patient record | occasionally correct documentaion in the patient record |
audit trail | CONTROL CREATED BY AN ELECTRONIC HEALTH SYSTEM AND LIST ALL THE TRANSACTIONS AND ACTIVITIES THAT HAVE Occured. |
addendum | an addition to the orignal chart entry |
preadmission testing | incorporates patient registration, testing, and other services into one visit prior to inpatient admission |
provisional diagnosis | preliminary diagnosis obtained from the attending physicican |
patient representative | the person who has legal responsibility over the patient |
nursing assesment | documents on the patients historty, medications, vitals, and nurses notes. |
reverse chronological date order | the most current document is on top |
chronological date order | arranged from first to last |
solo practicioner | a physician that practices alone |
secondary sourses | patient information contains data abstracted from primary sourses of patient info |
manual record | a paper record |
incidnt report | collects info about a potentially compensable event |
PCE | accident or injury report |
source orentiated record | maintains reports according to source of documentation |
sectionalized records | records divided into sections |
problem oriented recors | consists of 4 areas. database, problem list, initial plan, progress notes |
database | contains minimum set of data to be collected on eah patient |
problem list | acts as a table of contents for the overview of patient information and problems |
initial plan | describes actions that will be taken to learn more about the patients condition adn treatment |
diagnostice/management plans | plans to learn more about the patients condition and the management of the conditions |
theraputic plans | specific medications, goals, procedures, therapies, and treatments ised to treat the patient |
patients education plans | plans to educate the patient about the conditions for which the patient is being treated |
subjective | the patients statement about how they feel, including symptoms |
objective | observations about the patient such as physical findings or lab or xray results |