Chapter 26.

Question 1

Documentation

Answer 1

Written account of pertinent patient data, nursing clinical decisions and interventions, and patient response in a health record.

Question 2

Diagnosis related groups (DRGs)

Answer 2

Classifications based on a patients primary and secondary medical diagnoses that are used as the basis for establishing Medicare reimbursement for patient care.

Question 3

Health information technology for economic and clinical health act (HITECH)

Answer 3

Established provisions to promote the meaningful use of health information technology (HIT) to improve the quality and value of health care.

Question 4

Electronic health record (EHR)

Answer 4

Digital version of patient care that is found in traditional paper records. Lifetime record of all health care encounters for an individual patient.

Question 5

Electronic medical record (EMR)

Answer 5

Legal record that describes a single encounter or visit created in hospitals and out patient health care settings that is the source of date for the EHR.