Chapter 4 Flashcards
Definition:
Includes medical staff–approved abbreviations and symbols (and their meanings) that can be documented in patient records. When more than one meaning exists for an abbreviation, the facility should choose one meaning or identify the context in which the abbreviation is to be documented; The Joint Commission standards have not explicitly required an approved list of abbreviations since 1991; however, its National Patient Safety Goals prohibit the use of “dangerous” abbreviations, acronyms, and symbols in patient records, which include those that could be misinterpreted (e.g., D/C could be interpreted as discharge or discontinue).
abbreviation list
Definition:
Amending a patient record entry to clarify(avoid incorrect interpretation of information) or add additional information about previous documentation or to enter a late entry (out of sequence). Its purpose is to provide additional information, not to change documentation. The addendum should be documented as soon after the original entry as possible.
addendum
Definition:
Demographic, socioeconomic, and financial information.
administrative data
Definition:
State-mandated age of emancipation. Facilities must retain records for that state-mandated time period (such as 18 years) in addition to the retention law; also called age of majority.
age of consent
Definition:
Provide behavioral health, home health, hospice, outpatient, skilled nursing, and other forms of care. Also serve as the documentation source for patient care information.
alternate care facilities
Definition:
System for locating storage for patient records other than at the health care facility such as off-site storage, microfilm, or optical imaging.
alternative storage method
Definition:
Correction of an incorrect patient record entry by the author of the original entry. To amend an entry in a manual patient record system, the provider should draw a single line through the incorrect information, document a reason for the error, and enter the correct information. To amend an entry in an electronic health record system, the basic principles for correcting documentation errors are followed, and the electronic health record system should store both the original and the corrected entry as well as a record of who documented each entry
amending the patient record
Definition:
Records that are placed in storage and rarely accessed; also called inactive records.
archived records
Definition:
Portion of the POR progress note that documents judgment, opinion, or evaluation made by the health care provider.
assessment (A)
Definition:
Document intended to complement standards developed by other organizations and define a document structure for use by electronic signature mechanisms, the characteristics of an electronic signature process, minimum requirements for different electronic signature mechanisms, signature attributes for use with electronic signature mechanisms, acceptable electronic signature mechanisms and technologies, minimum requirements for user identification, access control, and other security requirements for electronic signatures, and technical details for all electronic signature mechanisms in sufficient detail to allow interoperability between systems supporting the same signature mechanism.
ASTM E 1762–Standard Guide for Authentication of Healthcare-Information
Definition:
List of all changes made to patient documentation in an electronic health record system, including all transactions and activities, date, time, and user who performed the transaction.
audit trail
Definition:
A patient record entry signed by the author (e.g., provider).
authentication
Definition:
Authentication of a dictated report by a provider prior to its transcription. This practice is not consistent with proper authentication procedures because providers must authenticate the document after it was transcribed.
auto-authentication
Definition:
Missing reports, documentation, and signatures as determined upon patient record analysis.
chart deficiencies
Definition:
Oldest information is filed first in a section of a discharged patient record. With integrated records, the order of reports is in strict date order, allowing the record to read like a diary.
chronological date order
Definition:
Health information obtained throughout treatment and care of patient. Includes health care information obtained about a patient’s care and treatment, which is documented on numerous forms in the patient record.
clinical data
Definition:
Authentication performed by an individual (e.g., attending physician) in addition to the signature by the original author of an entry (e.g., resident).
countersignature
Definition:
Documentation in the POR of a minimum set of data collected on every patient, such as chief complaint; present conditions and diagnoses; social data; past, personal, medical, and social history; review of systems; physical examination; and baseline laboratory data. Serves as an overview of patient information.
database
Definition:
Form or software completed by the health information analysis clerk and attached to the patient record, which is used to record or enter chart deficiencies that are noted in the patient’s record (e.g., missing physician signatures).
deficiency slip
Definition:
Records that remain incomplete 30 days after patient discharge (The Joint Commission standard).
delinquent records
Definition:
Statistic calculated by dividing total number of delinquent records by the number of discharges in the period.
delinquent record rate
Definition:
Patient identification information collected according to facility policy that includes the patient’s name and other information, such as date of birth, place of birth, mother’s maiden name, and social security number.
demographic data
Definition:
Category of POR’s initial plan that documents the patient’s condition and management of the condition.
diagnostic/management plans
Definition:
Storage solution that consolidates electronic records on a computer server for management and retrieval.
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digital archive
Definition:
Automated record system that contains a collection of information documented by a number of providers at different facilities regarding one patient; has the ability to link patient information created at different locations according to a unique patient identifier; provides access to complete and accurate health problems, status, and treatment data; and contains alerts (e.g., drug interaction) and reminders (e.g., prescription renewal notice) for health care providers.
electronic health records (EHR)
Definition:
Documents services received by a patient who has not been admitted to the hospital overnight, and includes ancillary services, emergency department services, and outpatient (or ambulatory) surgery; also called hospital ambulatory care record.
hospital ambulatory care record
Definition:
Documents the care and treatment received by a patient admitted to the hospital.
hospital inpatient record
Definition:
Documents services received by a patient who has not been admitted to the hospital overnight, and includes ancillary services, emergency department services, and outpatient (or ambulatory) surgery; also called hospital ambulatory care record.
hospital outpatient record
Definition:
Records that are placed in storage and rarely accessed; also called inactive records.
inactive records
Definition:
Collects information about a potentially compensable event (PCE); it is generated on patients and visits and provides a summary of the PCE in case the patient or visit files a lawsuit.
incident report
Definition:
Contains clinical information created by researchers, typically in academic medical centers.
independent database
