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chapter 2

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Term
Definition
abstracting   collection of data from the medical record for statistical and planning purpose.  
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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 diagnose with cancer  
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coding   assigning of numbers to diagnose and/or procedures using the current edition of a coding or classifiation system such as the international classification of diseases or current procedural  
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deficiency slip   a document that identifies deficiencies in documentation  
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healthcare provider   an individual of facility, such as hospital, that provides healthcare to patient.  
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JACHO   joint commission on the accreditation of healthcare organization.  
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litigation   lawsuit  
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medical record number   a unique number assigned to a medical records to identify it.  
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medical transcription   interpretation and typing of reports dictated by physician and other healthcare personnel.  
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medicare   federal insurance for patients over 65 or for the disabled.  
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performance improvment   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 journals published at specified periods, for example, weekly or monthly.  
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physician incomplete area   area of health information management department where physician come to work on incomplete records.  
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physician progress note   handwritten or typed entries made by the physician regarding the patients progress during hospitalization or other treatment  
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risk management   addressing the risk to witch patients, visitors, hospital staff, medical staff, vendors and others are exposed.  
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third party   a person or entity, such as an insurance company, other than the healthcare facility of patient.  
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Created by: Smileyjelly
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