Term | Definition |
assembly | arranging the documents of the medical records in a specified order after discharge of the patient |
authorization | a signed consent of the patient or his or her representative to release confidential information |
compromise care | to make the patient's care less effective |
contract service | a company hired to perform a function when the health information managenment department is usable to manage the amount of work, such as transripition of dictation |
discharge summary | a report, dictated by physician at the end of hospitalization, that details the diagnoses and treatment given |
health information management department | the department, in healthcare facility, responsible for maintaing security and confidentiality of patients records and for promoting responsible use of the records in patients care |
indexing | assigning a document to the correct patient, document type, and episode of care in an optical imaging system |
loose documents | documents received by the health information management department, after the patient has been discharged , that must be placed in the records |
medical transcription | interpretation and typing of reports dictated by physician and other healthcare personnel |
misflie | to file a record or document in the wrong location |
operative report | a report dictated by the surgeon detailing the surgical procedure and findings |
optical imaging system | a computer system in which documents are converted to computer image that can be viewed simultaneously by multiple user |
quality control | review of documents that have been scanned into an optical imaging system to insure that they are legible and have been indexed correcty |
scanning | the process of converting a paper document into a computer image |
medical records | a multiform documents detailing the patients diagnose, diagnostic testing, and treatment given during an encounter with the hospital. portions of the record may be computerized |