HIT 114 chapter 5
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| patient identification | patient name, nad other pieces of information
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| alias | an assumed name
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| addressograph machine | imprints patient identification on each report
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| facility identification | name of facility, address, telephone number on each report
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| face sheet | admission/discharge record. containes patient information, financail date, clinical data, demographic data
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| admitting diagnosis | provisional. condition or disease for which the patient is seeking treatment
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| final diagnosis | diagnosis found after evaluation and documentationby the physcian
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| Uniform hospital discharge data set | minimum core data set collected on the individual hospitaldischarges for the medicare and medicaid programs
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| principal diagnosis | condition established after study
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| secondary diagnoses | additional conditions for which the patient received treatment
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| comorbities | pre existing condition
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| complications | additional diagnosis that describe conditions arising after the beginning of the hospital stay
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| principal procedure | procedure performed for the definitive or theraputic reasons, rather than the diagnostic purposes
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| secondary procedures | additional procedures performed during inpatient stay
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| attestation statement | verifies diagnoses and procedures documented and coded at discharge
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| upcoding, maximizing coeds | documentation of procedures that require higher payment
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| advance directive notification form | a form signed by the patient to dicument that the patient has been notified of their right to have an advance directive.
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| advance directive | legal document in which patients provide instructions as to how they want to be treated in the event that they become very ill and there will be no hope for recovery
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| informed consent | the process of advising a patient about treatment options
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| consent to admission | generalized consent that documents a patients consent to receive medical treatment in the facility
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| patient property form | records items that the patients brings with them to the hospital
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| certificate of birth | is a record of birth information about the newborn patient and the parents
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| certificate of death | contains a record of information reguarding the decedent, family, cause of death, and the disposition of the body
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| emergency record | documents the evaluation and treatment of patients in the emergency room
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| ambulance report | documents a record of treatment by EMT on the ambulance ride
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| anti-dumping legislation | prevents facilities liscensed to provide emergency services from transfering patients who are unable to pay to other institutions, they must be stable before transfer.
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| discharge summary | provides information for continuity of care and facilities medical staff committee review
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| history | documents the chief complaint, history and patient info
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| interval history | documents a [atients history of present illness and any pertinet changes and physical findings since the previous hostory within 30 days
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| physical examination | an assesment of the patients body systems
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| differential diagnosis | indicaties that several diagnoses are being considered as possible
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| consultation | the provision of health care services by a consulting physcian whose opinion or advice is requested by another physcian
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| consultation report | documented by the consultant and included the consultants opinion and findings based on a physcial exam
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| physcians orders | direct diagnostic and theraputic patient care activities
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| health care proxy | power of attorney, legal document giving power of attorney
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| DNR | do not resuscitate
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| chief complaint- CC | patients description of medical condition
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| history of present illness- HPI | chronological description of patients condition
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| past history | summary of past illnesses
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| family history | review of family condition and illnesses
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| social history | age approiate rewview of past and current activities
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| review of systems- ROS | review of all body systems
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| dischare order | final order documented for dischagre
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| AMA | against medical advice
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| routine orders | physcians orders preapproved by the medical staff and placed in record
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| atanding order | orders for routine patients
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| stop order | patient safety mechanism, under circumstances treatment or meds may need to be stopped
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| telephone order-TO | verbal roder over the telephone to an authorized staff member
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| telephone call back order | requires the authorized staff memeber to read the order back
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| RAV | read and verified
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| Transfer order | transfer patient from one facility to another
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| verbal order | order through authorized staff member verbally
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| voice order VO | dictatced by authorized staff member
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| written order | orders are hand written and placed into electronic system
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| progress notes | contain statements on the course of patients conditions and illness and at discharge time
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| integrated progress note | all progress notes reported by doctores and nurses and other staff are organized together
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| admission note | documented by attending physcian at time of admission
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| follow up progresss note | daily progess notes by physcian
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| discharge progess note | final note upon discharge
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| case managemtn note | documented by case manager outlines discharge plan
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| dietary progress note | outlines diet plan by dietitian
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| rehab therapy progress note | documented by therapists
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| respiratory therapy progress note | documented by respiratory therapist
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| preanesthesia evaluation note | documented prior to medication
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| postanesthesia note | after surgery
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| preoperative note | condition before
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| postoperative | after surgery
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| anesthesia record | documents any anesthetic other than local
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| operative record | describes findings, organs examined and techniques used during operation
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| pathology report | documents the analysis of tissue removed and treatment
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| macroscopic | gross large view
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| ancillary report | documents by lab, radiology, and nuclear medicince departments
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| nursing documentation | anything documented by the nurses
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| nurse care plan | nursing interventions
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| nurse notes | daily observation
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| nurse discharge summary | discharge plan
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| graphic sheet | vital signs
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| medication administration record | documents medcation given
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| bedside terminal system | computer system at bedside for automated documents
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| obstetrical record | in the mothers record contains antepartum record
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| neonatal record | newborns record
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| antepartum record | shows health of nothers, family, pregnancy risk factors
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| labor and delivery record | records progress of the mother from time of admission through delivery
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| postpartum record | condition after delivery
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| birth history | summary of pregnancy, labor and delivery and newborns condition
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| newborn identification | footprints and fingerprints
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| newborn physical exam | assesment of newborn, dob, vs, height and weight
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| newborn progress notes | notes on newborn in nursery
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| autopsy | exam of body after death
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| provisional autopsy report | cause of death preliminary documentation 72 hours
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| autopsy report | 60 days and gives exact cause for death
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| ambulatory records | patient registration from similar inpatient face sheet
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| short stay record | less than 48 hours
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| abmulatory care data sheet | minimum core data collected for medicare and medicaid
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| outpatient visit | only a one day stay
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| encounter | professional contact between patient and provider
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| ancillary service visit | appearance of outpatient to ahospital department to receive test that was ordered
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| liscensed practioner | has a public liscense to deliever care to patients
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| non liscensed practictioner | doesnt have public liscense and is supervised by a liscensed practioner
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| formas committee | established to oversee this process and approve formas that are used in the record
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