Med Rec
Quiz yourself by thinking what should be in
each of the black spaces below before clicking
on it to display the answer.
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| Abstracting | collection of data from the medical record for statistical and planning purposes
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| Analysis | Reviewing the medical record to determine that all required documentation is present including signatures and reports
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| Cancer Registry | A database of patients diagnosed with cancer
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| coding | Assignment of numbers or diagnoses and or procedures using the current edition of a coding classification system such as the International Classification of Diseases or Current Procedural Terminology
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| Deficiency slip | A document that identifies deficiencies in documentation
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| Healthcare Provider | An individual or facility, such as a hospital, that provides healthcare to a patient
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| JCAHO | Joint Commission on the Accreditation of the Healthcare Organizations
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| Litigation | Lawsuit
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| Medical Record Number | A unique number assigned to a medical record in order to identify it
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| Medical Transcription | Interpretation and typing of reports dictated by physicians and other healthcare personnel
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| Medicare | Federal insurance for patients over 65 or for the disabled
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| Performance Improvement | Evaluating the overall performance of a healthcare facility, from the environment to patient care, with the purpose of continuous improvement
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| periodical | A magazine or journal published at specific periods, for example, weekly, or monthly
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| Physician incomplete area | Area of health info management department where physicians come to patient care , with the purpose of continuous improvement
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| Physician Progress Note | handwritten or typed entries made by the physician regarding the patient's progress during hospitalization or other treatment
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| Risk Management | Addressing the risk to which patients, visitors, hospital staff, vendors, and others are expposed
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| Third Party | A person or entity, such as insurance company, other than tthe healthcare facility or patient
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docdan
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