Ch 11: The Health Record Flashcards
Contents in the medical record
Concise account of the patient’s symptomsIn patient’s own wordsIncludes:
Nature, location, frequency, duration of pain, if any
When the patient first noticed these symptoms
Treatments the patient may have tried
Whether the patient has had the same or similar condition in the past
Other medical treatment received for the same condition in the past7
Chief Complaint
A electronic record of health-related information about a patient that conforms to nationally recognized interoperability standards and that can be created, managed, and consulted by authorized clinicians and staff from more than one healthcare organization
The EHR
This is an electronic record of health-related information about a patient that can be created, managed, and consulted by authorized clinicians and staff within a single healthcare organization
The EMR
This is an electronic record of health-related information about an individual that conforms to nationally recognized interoperability standards that can be drawn from multiple sources, but that is managed, shared, and controlled by the individual
The PNR
personal health record
Commonly known as the Economic Stimulus Package
Signed into law on February 17, 2009
Health information technology aspects of the bill provide slightly more than $31 billion for healthcare infrastructure and EHR investment
American Recovery and Reinvestment Act (ARRA)
This provides provides financial incentives for meaningful use of certified EHR technology to achieve health and efficiency goals
Was incorporated into ARRA to promote adoption and meaningful use of health information technology
HIPAA was created partly to simplify administrative processes using electronic devices
Meaningful use means providers must show that they are using EHR technology in ways that can be measured significantly in quality and quantity. To qualify 4 meaningful use:
Use of certified EHR in a meaningful manner, such as e-prescribing
Use of certified EHR technology for electronic exchange of health information to improve quality of healthcare
Use of certified EHR technology to submit clinical quality reports and other measures
HITECH Act and Meaningful Use
The age at which person is recognized by law to be an adult; can vary by state
Age of majority
To partly remove or correct; to relieve or lesson
Alleviate
Any system that arranges names or topics according to the sequence of the letters in the alphabet
Alphabetic filing
Of or relating to system is made up of combinations of letters and numbers
Alpha numeric
To increase in size or amount; to add to in order to improve or complete
Augment
The heading, title, or subtitle under which records are filed
Caption
The process of entering medication orders or other provider instructions into the electronic health record
Computerized provider\physician order entry
CPOE
Continuation of care smoothly from one provider to another, so that the patient receives the most benefits and no interruption in care
Continuity of care
Meriting condemnation, responsibility, or blame, especially as wrong or harmful
Culpability
The act or manner of other in words to be transcribed
Dictation
A filing system in which materials can be located without consulting and additional source of reference
Direct filing system
Do use of electronic software to communicate with pharmacies and send prescribing information, taking the place of writing a prescription by hand and physically giving it to a patient; most new order refill prescriptions can be submitted electronically, cutting down on fraud and errors
E -prescribing
And electronic record of health related information about a patient that conforms to nationally recognized interoperability Standards and that can be created, managed, and consulted by authorized clinicians and staff from more than one healthcare organization.
Electronic Health record
EHR
And electronic record of health related information about an individual that can be created, gathered, managed, and consulted by authorized clinicians and staff within a single healthcare organization
Electronic medical record
EMR
Gathered a bit by bit; picked over in search of the relevant material.
Gleaned
A filing system in which an intermediary source of reference must be consulted to locate specific files
Indirect filing system
The ability to work with other systems
Interoperability
A film with a photographic record of printed or other graphic material on a reduced scale
Microfilm
The filing of records, correspondence, or cards by number
Numeric filing
Data obtained through physical examination, laboratory and diagnostic testing, and by measurable information
Objective information
The act of making undecipherable or imperceivable by obscuring or wearing away.
Obliteration
A sturdy cardboard or plastic file size card used to replace a folder temporarily removed from the filing space
Out guide
Any set of physical properties, the values of which determine characteristics or behavior
Parameters
A secure online website that gives patients 24 hour access to personal health information using a username and password
Patient portal
And electronic record of health related information about an individual that conforms to nationally recognized inter-operability standards and that can be drawn from multiple sources but that is managed, shared, and controlled by the individual
Personal health record
PHR
A strong, highly glazed composition board resembling vulcanized fiber; heavy card stock
Pressboard
A temporary diagnosis made it before all test results have been received
Provisional diagnosis
The process of moving active files to in active status
Purging
And aggregate of activities designed to ensure adequate quality, especially in manufactured products or in the service industry’s
Quality control
Circumstances that would make it unreasonable for that covered entity, despite the exercise of ordinary business here and prudence, to comply with the administrative simplification provision of the HITECH act that was violated.
Reasonable cause
The business care and prudence expected it from a person seeking to satisfy a legal requirement under Similar circumstances
Reasonable diligence
Entities considered a essential or necessary
Requisites
A method or plan for retaining or keeping health records and for their movement from active to inactive to closed filing
Retention schedule
Arranged in order so that the most recent item is on top and older items are filed in the back
Reverse chronological order
Data or information from the patient, including the patients feelings, perceptions, and concerns; obtained through interviewing or questions
Subjective information
A court order to produce documents or records
Subpoena duces tecum
A chronological file used as a reminder that something must be dealt with on a certain date
Tickler file
A written copy of something made either in longhand or by machine
Transcription
Granted or endowed with a particular authority, right, or property; to have a special interest in
Vested
Conscious, intentional failures or reckless indifference to the obligation to comply with the administrative simplification provision violated
Willful neglect
