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32 Cards in this Set

  • Front
  • Back

patient information

facts about the patient






(also known as patient demographics)

symptom

a change in health function experienced by a patient

healthcare worker

a person who participates directly or indirectly in providing healthcare services to a patient




(can be a: doctor, medical secretary, nurse, physician’s assistant, nurse’s aide, admissions clerk, laboratory or radiology technician, and many others)

accredit

to endorse or approve officially

acceptable documentation

complete, legible, and chronological account of the care provided to the patient as represented in the medical record

concurrent review

review of the medical record done while the patient is in the hospital






(the benefits of this type of review are that documentation issues can be identified at the time of patient care and rectified in a timely manner)

documentation standards

standards developed by different organizations to ensure the uniformity, accuracy, completeness, legibility, authenticity, timeliness, frequency, and format of medical record entries




(for example, The Joint Commission)

The Joint Commission

organization which accredits hospitals and other healthcare organizations based on accreditation standards, including documentation standards

occurrence screening

technique in which the medical record of current and discharged patients is reviewed with the goal of identifying potential compensable events (accident or medical error which results in a personal injury or loss of property) -- occurrences include instances when a wrong surgery was performed or an informed consent for a procedure was not obtained.

qualitative analysis

review of the medical record to ensure that standards are met and to determine the accuracy of documentation

quantitative analysis

review of the medical record to determine its completeness

retrospective review

review of the medical record after the patient has been discharged






(this type of review does not allow for timely identification of documentation issues)

risk management

medical, legal, and administrative operations within a healthcare organization to minimize the exposure to liability -- complete and accurate medical record documentation is the foundation for effective risk management

unacceptable documentation

unclear or incomplete medical record documentation






(for example, inconsistent entries)

vocabulary standards

common definitions of medical terms which encourage consistent descriptions of a patient's conditions in the medical record

EHR - ease of storage

an EHR benefit that helps save space when storing records

EHR - accessibility

an EHR benefit that offers easy and immediate access to information

EHR - efficiency

an EHR benefit wherein information is accessible the moment it’s entered to whoever needs it

EHR - searchability

an EHR benefit that expedites the time it takes to search for an item and makes it easier to find

Systematized Nomenclature of Medicine




(SNOMED)

a standardized medical vocabulary used to facilitate the indexing, storage, and retrieval of patient information in an electronic health record

paper-based record

medical record data printed and stored on paper in hard copy format

electronic-based record

edical record data stored in an electronic format in a computer system or systems

EHR - collaboration

an EHR benefit wherein information sharing is made easier

health information exchange

the use of information technology to improve the quality, safety, efficiency, and confidentiality of healthcare through simultaneous access to patient health information by multiple healthcare providers

EHR - uniformity and standardization

an EHR benefit in which health record systems adhere to structure and content standards

EHR - structure and content standards

common elements and definitions to be included in an electronic health record

health informatics standards

structure and content standards that must be maintained in a health record

EHR - reduction in medical errors

when records are available quickly, are easily searched, and updates are easy to make, the opportunities for patient care errors are reduced

subjective component




(of clinic note)

a narrative of the patient’s own description of his/her complaints -- this would include any past history or review of systems, allergies, or medication lists that are provided

objective component




(of clinic note)

the description of the physician’s findings on observation and examination, any physical signs, and laboratory testing or diagnostic studies, such as x-rays

assessment component




(of clinic note)

how the physician interprets the findings (both subjective and objective) -- in other words, this is the physician’s opinion, impression, assessment, or diagnosis

plan component




(of clinic note)

treatment and followup -- this includes any medication regimen, instruction (such as elevation or cleansing), suggested education, and followup instruction