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key terms (flashcards)

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Answer
Addresssograph machine   plastic card containing patient identification; used to imprint info. on ea. report in the patient record.  
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Admission note   progress note documented by the attending m.d. at the time of patient admission.  
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Admission/Discharge Record   (face sheet) contains patient identification( or demo-graphic), finanical, and clinical info (or data). normally filed in the beginning of the chart.  
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Admitting Dx   provisional dx-- working tentative, admission, & preliminary dx obtained from the attending phy.; it is the dx upon which inpatient care is initially based.  
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**advance directive**   legal document that provides instructions as to how patients want to be treated in the event they b/c very ill & there is no reasonalbe hope for recovery.  
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Advance directive notification form   Signed by the patient as proof they were notified of their right to have an advance directive.  
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Against Medical Advice (AMA)   Pt's who sign themselves out of a facility & sign a release from responsibility for discharge.  
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Alias   An assumed name.  
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Ambulance Report   generated by EMT--Emergency medical technicians to document clinical info. such as vital signs,level of consciosness, appearance of the pt. original record kept w/the ambulance company --copy goes to the ED--emergency dept.  
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Ambulatory Record   documents services recieved by a pt who has not been admitted to the hosp. overnight, & includes ancillary services, ED sevices, outpatient(or ambulatory) surgery; also called hospital ambulatory care record.  
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Ancillary Reports   documented by such departments as laboratory, radiology, nuclear medicine to assist physician in dx & treatment of pt's  
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Ancillary service visit   Appearance of an outpt. to a hosp. dept. to recieve an ordered service, test or procedure; also called occasion of service.  
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anesthesia record   required when a pt. recieves an anesthetic other than a local anesthetic to document pt. monitoring during administration of anesthetic agents and other activities related to the surgical episode.  
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antepartum record   gernerated in the physician's office which includes health hx of the mother,family & social hx, pregnancy risk factors, care during pregnancy including tests performed, & medications administered, also called prenatal record.  
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anti-dumping legislation   (EMTALA)-Emergency Medical Treatment & Labor Act:addressed the problem of hospitals failing to screen,treat,or appropriatly transfer patients (pt.dumping)by establishing criteria for the discharge & transfer of HMB & HMAB pt's also called the anti-dumping  
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APGAR score   Measures a baby's appearance(e.g.(A) skin color),pulse(P),grimace(G),(eg.,irritability), activity(A)(eg.,muscle tone & motion), & respirations (R) on a scale of 1 to 10(with up to 2 pts assigned for ea. measurement & 10 being the maximum score).  
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attestation statement   (5)signed by the attending physician to verify diagnonses & procedures documented & coded @ discharged of a hospital pt.;discontinued in 1995.  
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automatic stop order   stop order>as a pt. safety mechanism,state law mandates-standing physician orders are automatically discontinued(stopped),requiring the physician to document a new order.  
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autopsy   an examination of a body after death- to the determind cause of death.  
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autopsy report   To be documented within 60 days and contains summary of pt's clinical hx including diseases,surgical hx, & tx; detailed results.  
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bedside terminal system   Computer system located at the pt's bedside. Used to automate nursing documentation;patient information can be entered,stored retrieved, and displayed.  
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birth certificate   certificate of birth  
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birth history   documents summary of pregnancy,labor & delivery, and newborn's condition @ birth.  
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case management note   progress note documented by a case manager. Outlines a discharge plan that includes case management/social services provided & pt. education.  
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certificate of birth   Record of birth information about the newborn patient & the parents, & identifies medical information regarding the pregnancy & birth of the newborn; also called birth certificate.  
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certificate of death   Contains a record of information regarding the decedent, his or her family, cause of death, and the disposition of the body; also called death certificate.  
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chief compliant (CC)   pt.'s description of medical condition, stated in the pt.'s own words.  
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clinical data   Health information obtained throughout treatment & care of patient.  
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clinical resume   discharge summary  
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comorbidities   pre-existing condition that will, because of its presence with a specific prinicipal diagnosis, cause an increase in the pt's length of stay by at least on day 75% of the cases (e.g. dibetities, enemia)  
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**complications**   additional diagnosis that describe conditions arising after the beginning of hospital observation and treatment & that modify the course of the pt's illness or the medical care required; they prolong the pt's length of stay by at least one day.  
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condition of admission   consent to admission  
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consulation   Provision of health care services by a consulting physician whose opinion or advice is required by another physician.  
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consultation report   Documented by the consultant & includes the consultant's opinion & findings based on a physical examination & review of pt. records.  
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death certificate   certificate of death  
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dietary progress note   Progress note documented by the dietitian(or authorized designee) which includes pt's dietary needs & any dietary observation made by staff.  
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differential diagnosis   Indicates that several diagnoses are being considered as possible.  
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discharge note   Final progress note documented by the attending physician. Includes pt's discharge destination,discharge medications,activity level allowed, & follow-up plan.  
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discharge order   Final physician order documented to release a pt. from a facility.  
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discharge summary   Provides information for continuity of care & facilitates medical staff committee review; documents the pt's hospitalization, including reson(s) for hospitaliztion, course of treatment, and condition at discharge; also called clinical resume.  
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doctors orders   physician orders  
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DRG Creep   upcoding  
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durable power of attorney   health care proxy  
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emergency record   documents the evaluation & treatment of pt's seen in the facility's emergency department for immediate attention of urgent medical conditions or traumatic injuries.  
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encounter   Professional contact between a pt. & a provider who dilivers services or is professionally responsible for services delivered to a pt.  
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encounter form   Commonly used in physician offices to capture charges generated during an office visit & common services provided in the office. AKA superbill or fee slip.  
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face sheet   Contains pt's indentification (or demographic), financial, and clinical information (or data).  
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facility identification   name of the facility,mailing address,and a telephone number, included on each report.  
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family history   review of the medical events in the pt's family, including disease which may be hereditary or present a risk to the patient.  
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fee slip   encounter form  
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final diagnosis   Diagnosis determined after evaluation & documented by the attending physician upon discharge of the patient from the facility.  
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follow-up progress note   daily progress notes documented by the responsible physicians. includes pt's condition,findings on examination,significant changes in condition and/or diagnosis,respose to medications administered,response to clinical treatment,abnormal test finding,and t  
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forms comittee   Established to oversee the process of adding, deleting, and changing forms and to approve forms used in the record.  
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graphic sheet   documents patient's vital signs (e.g., temperture,pulse,respiration,blood pressure,and so on) using graph for easy interpretation of data.  
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health care proxy   Legal document (recognized by New York State) in which the pt. chooses another person to make treatment decisions in the event the pt. becomes incapable of making these decisions.  
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history   documents the pt's chief complaint,history of present illness (HPI),past/family/social history(PFSH) and review of systems (ROS).  
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history of present illness (HPI)   Chronilogical description of pt's present condition from time of onset to present; should include location,quality,severity,duration of the condition, and associated signs and symptoms.  
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informed consent   Process of advising a patient about treatment options and, depending on state laws, the provider may be obligated to disclosed a patient's diagnosis, proposed treatment/surgery,reason for the treatment/surgery,possible complications,likelihood of success,  
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intergrated progress notes   Progness notes documented by physicians,nurses,physical therapists,occupational therapists, and other professional staff members are organized in the same section of the record.  
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interval history   documents a pt's history of present illness and any pertinent changes and physical findings that occurred since a previous inpatient admission if the patient is readmitted within 30 days after discharge for the same condition.  
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labor and delivery record   Records progress of the mother from time of admission through time of delivery; infromation includes time of onset of contractions,severity of contractions,medications administered,patient and fetal vital signs, and progression of labor.  
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licensed practitioner   Required to have a public license/certification to deliver care to patients.  
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macroscopic   Gross examination of tissue; visible to the naked eye.  
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maximizing code   upcoding  
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medication administration record (MAR)   Documents medications administered,data and time of administration, name of drug,dosage,route of administration,and initials of nurse administering medication.  
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necropsy   the character or extent of changes produced by disease.(autopsy)  
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necropsy report   autopsy report  
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neonatal record   Newborn's record that contains a birth history,newborn identification,physical examination,and progress notes.  
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newborn identification   Immediately following birh,footprints and fingerprints of the newborn are created, and a wrist or ankle band is placed on the newborn(with an identical band placed on the mother).  
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newborn physical examination   An assessment of the newborn's condition immediately after birth, including time and date of bith, vital signs, birth weight and lenth, head and chest measurements,general appearance and physical findings.  
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newborn progress notes   Documents information gathered by nurses in the nursery and includes vital signs, skin color, intake and output, weight, medications and treatment, and observations.  
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non-licensed practitioner   Does not have a public license/certification and is supervised by a licensed/certified professional in the delivery of care to patients.  
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nures notes   Documents daily observation about patients, including an initial history of the patient, patient's reactions to treatments, and treatments rendered.  
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nursing care plan   Documents nursing diagnosis as well as interventions used to care for the patient.  
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nursing discharge summary   Documents patient discharge plans and instructions.  
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nursing documentation   Crucial to patient care because the majority of care delivered to inpatients is performed by nursing staff.  
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obstetrical record   Mother's record that contains an antepartum record, labor and delivery record, and postpartum record.  
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occasion of service   ancillary service visit(e.g. labs,ordered service,or procedure).  
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operative report   describes gross findings,organs examined(visually or palpated),and techniques associated with the performace of surgery.To be dictated or handwritten immediately following the operation and authenticated by the responsible surgeon.  
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outpatient visit   Visit of a patient on one calendar day to one or more hospital departments for the purpose of receiving outpatient health care services.  
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Past history   summary of past illnesses,operations,injuries,treatments, and known allergies.  
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pathology report   Assists in the analysis and treatment of patients by documenting the analysis of tissue removed surgically or diagnostically, or that expelled by the patients; also called tissue report.  
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patient identification   pt's name and some other piece of identifying information such as medical record number, date of birth,or social security number.  
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patient property form   Records items patients bring with them to the hospital.  
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patient record commitee   forms committee  
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phycial examination   Assessment of the pt's body systems to assist in determining a diagnosis, documenting a provisional diagnosis, which may include differential diagnoses.  
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physician office record   documents patient health care services recieved in a physician's office.  
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physician orders   Direct the diagnostic and therapeutic patient care activities; also called doctors orders.  
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postanesthesia note   Progress note documented by the anethesiologist.  
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postmortem report   autopsy report  
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postoperative note   Progress note documented by the surgeon after surgery.Documents the pt's response to surgery and a postoperative diagnosis.  
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postpartum record   Documents information concerning the mother's condition after delivery.  
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preanesthesia evaluation note   Progress note documented by the anesthesiologist prior to the induction of anesthesia.  
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prenatal record   antepartum record  
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preoperative note   Progress note documented by the surgeon prior to surgery. Summarizes the pt's condition and documents a preoperative diagnosis.  
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primary diagnosis   Reason the patient sought treatment during that encounter; reflects the current, most significant reason for services provided or procedures performed.  
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**principal diagnosis**   condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care.  
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**principal procedure**   Procedure performed for definitive or therapeutic reasons,rather than diagnostic purposes, or to treat a complication, or that procedure which is most closely related to the principal diagnosis.  
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progress notes   Contain statements related to the course of the patient's illness,response to treatment, and status at discharge.  
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provisional autopsy report   Contains a cause fo death and is to be documented within 72 hours(3days).  
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read and varified (RAV)   Abbreviation entered by staff member who documents a telephone order to document that the telephone order call-back policy was followed.  
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recovery room record   Delineates care administerd to the patient from the time of arrival until the patient is moved to a nursing unit.  
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rehabilitation therapy progress note   Progress notes documented by various rehabilitation therapists that demonstrated the pt's progress(or lack thereof)toward established therapy goals.  
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respiratory therapy progress note   Progress notes documented by respiratory therapists.  
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review of systems   Inventory by systems to reveal subjective symptoms stated by the patient; provides an opportunity to gather information that the patient may have forgotten to mention or that may have seemed unimportant.  
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routine order   Physician orders preapproved by the medical staff,which are preprinted and placed on a pt's record.  
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**secondary diagnosis**   additional conditions for which the patient received treatment and/or impacted the inpatient care.  
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**secondary procedure(s)**   additional procedure(s) performed during inpatient admission.  
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short stay   An uncomplicated hospital stay of less than 48 hours.  
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short stay record   Allows providers to record the patient's history, physical examination,progress notes,physician orders, and nursing documentation on one double-sided form.  
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social history   Age-appropriate review of past and current activities such as daily routine,dietary habits,excercise routine, marital status,occupation,sleeping patterns,smoking,use of alcohol and other drugs,sexual activities,and so on.  
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standing order   physician orders preapproved by the medical staff that direct the continual administration of specific acitivities for a specific period of time as a part of diagnostic or therapeutic care.  
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stop order   as a pt. safety mechanism,state law mandates, and in the absence of state law facilities decide,for which circumstances preapproved standing physician orders are automatically discontinued (stopped),requiring the physician to document a new order.  
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superbill   encoutner form  
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telephone order call back policy   requires the authorized staff member to read back and verify what the physician dictated to ensure that the order is entered accuratley.  
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tissue report   pathology report  
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transfer order   physician order documented to transfer a patient from one facility to another.  
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Uniform Ambulatory Care Data Set (UACDS)   Minimum core data set collected on Medicare oand Medicaid outpatients.  
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Uniform Hospital Discharge Data Set (UHDDS)   Minimum core data set collected on individual hospital dicharges for the Medicare and Medicaid programs; much of this information is located on the face sheet.  
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**upcoding**   documentation of diagnosis and procedures that result in higher payment for a facility;also call maximizing codes or DRG Creep.  
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verbal order   Orders dictated to an authorized facility staff member because the responsible physician is unable to personally document the order.  
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written order   Orders that are handwritten in a paper-based record or entered into an electronic health record by the responsible physician.  
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