Health Data Management: Clinical Information And Observations

Front 1

Administrative information

Back 1

includes personal info about the patient, including consents, insurance coverage, nature of admission and chief complaint. Usually collected before or during the admissions proceess.

Front 2

Clinical information

Back 2

documents patient's condition and course of treatment, including medical history and physicians' orders

Front 3

UHDDS

Back 3

Uniform Hospital Discharge Data Set

Hint 3

uniform healthcare data set hospitals must use for inpatient services.

Front 4

UACDS

Back 4

Uniform Ambulatory Care Data Set

Hint 4

uniform healthcare data set hospitals must use for outpatient services.

Front 5

DEEDS

Back 5

Data Elements for Emergency Department Systems

Hint 5

data set developed for use in Emergency and trauma units, however use by hospitals is voluntary

Front 6

Demographic data

Back 6

includes basic factual info about an individual patient, such as name, address, gender, marital status, next of kin and admission date

Front 7

Advance directive

Back 7

document that describes the patient's healthcare preferences in the event that he or she is unable to communicate directly at some point in the future.

Front 8

history

Back 8

summary of patient's illness from his or her point of view.

Front 9

Chief Complaint

Back 9

the reason the patient is seeking medical treatment.

Front 10

CPOE

Back 10

Computerized physician order entry

Front 11

Progress notes

Back 11

records of clinical observations; aka encounter or visit note

Front 12

Care plan

Back 12

a mulidisciplinary tool for organizing the diagnostic and therapeutic services to be provided to a patient.

Front 13

NGC

Back 13

National Guideline Clearinghouse

Hint 13

an initiative of the Agency for Healthcare Research and Quality (AHRQ)

Front 14

Case management

Back 14

process of ongoing and concurrent review performed to ensure the medical necessity and effectiveness of the clinical services being provided to the patient.

Front 15

Charting by exception

Back 15

aka focus charting. Only abnormal or unusual findings are documented

Front 16

Medication record

Back 16

includes all medications administered to a patient while the patient is in the nursing unit. Other units maintain separate medication records

Front 17

Flow charts

Back 17

graphic illustrations of data and observations; make it eas to visualize patterns and identify abnormal results.

Front 18

Transfer records

Back 18

important to continuum of care because they document communication between caregivers in multiple settings.

Front 19

Ancillary services

Back 19

include laboratory and imaging procedures performed in their respective departments.

Front 20

EMTALA

Back 20

Emergency Medical Treatment and Active Labor Act

Hint 20

requires emergency departments to complete a medical screening exam prior to collecting any info regarding patient's ability to pay for services

Front 21

PAI

Back 21

patient assessment instrument

Hint 21

must be completed soon after a patient's admission and upon discharge.

Front 22

CARF

Back 22

Commission on Accreditation of Rehabilitation Facilities

Hint 22

requires rehab facilities to maintain a single case record for every patient they admit

Front 23

Complication

Back 23

a condition that began after the patient was admitted for inpatient care

Front 24

Comorbidities

Back 24

preexisting conditions that affected the patient's care