Term | Definition |
Abstracting | Collection of data from the medical record for statistical and planning purposes. |
Analysis | Reviewing the medical record to determine that all required documentation is present including signatures and reports. |
Cancer registry | A database of patients diagnose with cancer. |
Coding | Assignment of numbers to diagnoses and/or procedures using the current edition of a coding or classification system such as the International Classification of Diseases (ICD) or Current Procedural Terminology (CPT). |
Deficiency slip | A document that identifies deficiencies in documentation. |
Healthcare provider | An individual or facility, such as a hospital, that provides healthcare to a patient. |
JCAHO | Joint Commission on the Accreditation of Healthcare Organizations. |
Ligitation | Lawsuit. |
Medical record number | A unique number assigned to a medical record in order to identify it. |
Medical transcription | Interpretation and typing of reports dictated by physicians and other healthcare personnel. |
Medicare | Federal insurance for patients over 65 or for the disabled. |
Performance improvement | Evaluating the overall performance of a healthcare facility, from the environment to the patient care, with the purpose of continuous improvement. |
Periodical | A magazine or journal published at specified periods, for example, weekly or monthly. |
Physician incomplete area | Area of the health information management department where physician regarding the patient's progress during hospitalization or other treatment. |
Physician progress note | Handwritten or typed entries made by the physician regarding the patient's progress during hospitalization or other treatment. |
Risk management | Addressing the risk to which patients, visitors, hospital staff, medical staff, vendors, and others are exposed. |
Third party | A person or entity, such as an insurance company, other than the healthcare facility or patient. |