HIT 114 Chapter 4
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| alternative care facilities | provide behavioral health, home health, hospice, outpatient,skilled nursing and other formas of care also serve as documentation patient care information.
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| patient record | a business record for a patient encounter, contains dicumentation of all health services.
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| 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...
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| 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.
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| report generation | construction of a healthcare document, consists of formatting and structuring of captured information
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| continuity of care | the primary purpose of the patient record.
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| hospital impatient record | documents the care and treatment received by a patient admitted to the hospital
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| administrative data | includes demograhphic, socioeconomic, and financial data
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| clinical data | includes all info about the patients health and treatment throught the care process
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| hospital outpatient record | documents services received by a patient who has not been admitted into the hospital
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| authentication | the entry must be signed by the author
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| countersignature | a form of authentication by an individual in addition to the signature of the orginal author
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| telephone order | is a verbal order over the phone by a qualified professional from aphysician
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| voice order | the physician dictates an order in the presence of a responsible person. this practce is no longer used.
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| signature legend | a complete signature that matches initial that are on a record
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| electronic signatures | is a generic term that refers to the variuos methods of electronic documents that are authenticated electronically.
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| digital signature | is created using a public key cryptograophy to authtenticate a dicument
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| public key cryptography | uses an algothrium of 2 keys , one for creating the digital signature by transforming data and other to verify the key.
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| signature stamps | a stamp that has an authorized signature on it
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| abbreviation list | includes a list of medical abbreviation that are approved by staff
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| deliquent records | records that aren't processed before the 30 days mark after a patient is discharged
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| amending the patient record | occasionally correct documentaion in the patient record
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| audit trail | CONTROL CREATED BY AN ELECTRONIC HEALTH SYSTEM AND LIST ALL THE TRANSACTIONS AND ACTIVITIES THAT HAVE Occured.
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| addendum | an addition to the orignal chart entry
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| preadmission testing | incorporates patient registration, testing, and other services into one visit prior to inpatient admission
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| provisional diagnosis | preliminary diagnosis obtained from the attending physicican
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| patient representative | the person who has legal responsibility over the patient
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| nursing assesment | documents on the patients historty, medications, vitals, and nurses notes.
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| reverse chronological date order | the most current document is on top
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| chronological date order | arranged from first to last
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| solo practicioner | a physician that practices alone
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| secondary sourses | patient information contains data abstracted from primary sourses of patient info
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| manual record | a paper record
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| incidnt report | collects info about a potentially compensable event
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| PCE | accident or injury report
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| source orentiated record | maintains reports according to source of documentation
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| sectionalized records | records divided into sections
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| problem oriented recors | consists of 4 areas. database, problem list, initial plan, progress notes
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| database | contains minimum set of data to be collected on eah patient
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| problem list | acts as a table of contents for the overview of patient information and problems
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| initial plan | describes actions that will be taken to learn more about the patients condition adn treatment
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| diagnostice/management plans | plans to learn more about the patients condition and the management of the conditions
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| theraputic plans | specific medications, goals, procedures, therapies, and treatments ised to treat the patient
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| patients education plans | plans to educate the patient about the conditions for which the patient is being treated
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| subjective | the patients statement about how they feel, including symptoms
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| objective | observations about the patient such as physical findings or lab or xray results
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