Essentials of HIM- Chapter 4- Introduction to the Patient Record
Terms in this set (32)
Demographic, socioeconomic and financial information
amending patient record
To change something in record only by the author of the record; follow protocol
Portion of problem oriented record that documents judgment, opinion, or evaluation
Missing reports, documentation, and signatures as determined upon patient record analysis
chronological date order
Oldest information is filed first in a section of a discharged patient record.
Information obtained through treatment and care of patient; i.e., testing, surgeries, medical information
Authentication performed by an individual (physician) in addition to original author of an entry (resident).
Documentation in record of minimal set of data collected on every patient.
Form completed by health information analyst attached to patients chart for completion
Patient information such as name, address, date of birth, and social security number.
Collects information about a potentially liable event. This is never put in patient record; only for legal department (Risk Management)
Records that are incomplete after 30 days following patient discharge
Process of recording representations of human thought, perceptions, or actions in documenting patient care (doctor's dictation)
Documentation in problem oriented record that describes initial actions to take place in patient treatment
Format usually arranges reports in strict chronological date order.
Documents patient history, current medications, and vital signs on forms
Part of problem oriented record that documents observations about patient, physical findings, lab data, etc.
Patient education plan
Documents patient teaching about disease and treatments.
Portion of progress note that documents diagnostic, therapeutic, and educational plans to resolve problems
Preadmission testing (PAT)
Patient registration and testing prior to inpatient admission (EKG, Chest X-ray, Blood Work)
Primary sources (of information)
Include original patient records, x-rays, scans, EKG's and other documents of clinical findings
Working, tentative, admission and preliminary diagnosis obtained from the attending physician.
Problem oriented record
Systematic method of documentation consisting of four parts: database, problem list, initial plan, progress notes
Consists of formatting or structuring captured information on patients
Reverse chronological order
Most current documentation is filed first in a section of the inpatient record
secondary sources (of information)
Patient information that contains data abstracted from primary sources (communication, indexes and registers, committee minutes, incident reports
Portion of POR that states patient's perception of how he or she feels (Patient's point of view of what's wrong)
telephone orders (TO)
A verbal order taken by phone from physician or qualified health care professional
Documented when patient is being transferred to another facility. Summarizes reasons for admission and treatment given.
Voice order (VO)
Physician dictates an order in presence of responsible person; no longer accepted practice