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32 Cards in this Set
- Front
- Back
patient information |
facts about the patient (also known as patient demographics) |
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symptom |
a change in health function experienced by a patient |
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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) |
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accredit |
to endorse or approve officially |
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acceptable documentation |
complete, legible, and chronological account of the care provided to the patient as represented in the medical record |
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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) |
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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) |
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The Joint Commission |
organization which accredits hospitals and other healthcare organizations based on accreditation standards, including documentation standards |
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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. |
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qualitative analysis |
review of the medical record to ensure that standards are met and to determine the accuracy of documentation |
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quantitative analysis |
review of the medical record to determine its completeness |
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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) |
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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 |
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unacceptable documentation |
unclear or incomplete medical record documentation (for example, inconsistent entries) |
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vocabulary standards |
common definitions of medical terms which encourage consistent descriptions of a patient's conditions in the medical record |
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EHR - ease of storage |
an EHR benefit that helps save space when storing records |
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EHR - accessibility |
an EHR benefit that offers easy and immediate access to information |
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EHR - efficiency |
an EHR benefit wherein information is accessible the moment it’s entered to whoever needs it |
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EHR - searchability |
an EHR benefit that expedites the time it takes to search for an item and makes it easier to find |
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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 |
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paper-based record |
medical record data printed and stored on paper in hard copy format |
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electronic-based record |
edical record data stored in an electronic format in a computer system or systems |
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EHR - collaboration |
an EHR benefit wherein information sharing is made easier |
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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 |
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EHR - uniformity and standardization |
an EHR benefit in which health record systems adhere to structure and content standards |
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EHR - structure and content standards |
common elements and definitions to be included in an electronic health record |
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health informatics standards |
structure and content standards that must be maintained in a health record |
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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 |
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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 |
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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 |
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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 |
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plan component (of clinic note) |
treatment and followup -- this includes any medication regimen, instruction (such as elevation or cleansing), suggested education, and followup instruction |