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Healthcare Documentation Essentials > Chapter 4 > Flashcards

Chapter 4 Flashcards

1
Q

Patient Record

A

The business record for a patient encounter, contains documentation of health care services provided to a patient, includes demographic data, documentation to support, diagnosis, justify treatment, and records results

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2
Q

Demographic Data

A

Patient identification information collected according to facility police and includes the patient’s name, dob, ss#, place of birth, mother’s maiden name, facility name, mailing address and telephone #

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3
Q

MRI

A

Medical Record Institute

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4
Q

Information Capture

A

the process of recording representations of human thought, perceptions, or action in documenting patient care.

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5
Q

Report Generation

A

The construction of a health care document

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6
Q

Medical Transcription

A

Involves keyboarding medical information dictated by a provider into a system that stores a dictation on tape or using computer media such as a heard drive or disc.

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7
Q

Medical Trascriptionist

A

Certified through the Association for Healthcare Documentation Integrity (AHDI. Listens to the dictated information and keyboards the report.

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8
Q

Speech Recognition Software

A

AKA Voice Recognition Software. Translates the spoken word into text.

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9
Q

Voice Recognition Software

A

AKA Speech Recognition Software. Translates the spoken word into text.

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10
Q

Purpose of the Patient Record

A

According to the Joint Commission the purpose is to identify the patient, support and justify the patient diagnosis, care, treatment, and services provided, and facilitate continuity of care among healthcare providers.

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11
Q

Secondary Purposes for the Patient Record

A

Do not relate directly to the patient care and include evaluating quality, providing info to 3rd party payers (insurance co) for reimbursement, serving interests of the patient, facility, and providers of care, and providing data for use in clinical research, studies, education, public policy making, facilities planning, and healthcare statistics.

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12
Q

Ownership of the Medical Record

A

The medical record is the property of the provider, and as governed by state and federal laws, the patient has rights access the contents for review and to request that inaccurate info be amended. The provider owns the documents and maintains possession of the original record according to federal regulations. (ie Mediate, State Laws, etc. The provider may maintain the record on its premises or on an offsite storage facility.

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13
Q

Electronic Health Care Record (EHR)

A

AKA Electronic Medical Records (previously computer based patient records.)

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14
Q

Electronic Medical Record

A

AKA Electronic Healthcare Record

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15
Q

Hospital Inpatient Record

A

Documents the care and treatment received by a patient admitted to the hospital.

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16
Q

Administrative Data

A

Includes demographic, socioeconomic, and financial information.

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17
Q

Clinical Data

A

Includes all the patient health information obtained throughout the treatment and care of the patient, treating the patient

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18
Q

Hospital Outpatient Record

A

AKA: Hospital Ambulatory Record. Documents services received by a patient who has not been admitted to the hospital, such as labs, x-rays, ER services, and outpatient surgery.

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19
Q

Hospital Ambulatory Record

A

AKA: Hospital Outpatient Record

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20
Q

Physician Office Record

A

Patient healthcare services received in a physician’s office.

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21
Q

Alternate Care Clinical Data

A

Ambulatory, Behavioral Health, Clinical Lab, Home Care, Long Term Care, Surgical Centers (Stand Alone)

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22
Q

Joint Commission RC.01.02.01

A

Only authorized individuals can makes entries in the medical record. Entries are authenticated by the author For counter signatures hospitals must define the types of entries in the medical record made by nonindependent practitioners that require countersigning (ie. Dr and Intern).

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23
Q

“If it wasn’t documented, it wasn’t done.”

A

If it isn’t documented the patient or 3rd party rep can refuse to pay, cannot be admitted as evidence in court.

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24
Q

Authentication

A

Means an entry is signed by the author. ONLY the author of an entry can authenticate the entry, thus establishing accuracy and verification. (Federal Regulations/Interpretive Guidelines for Hospitals (482.24(c)((1)(i) published by the Centers for Medicare and Medicaid Services)

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25
Q

Auto-Authentication

A

Involves a provider authenticating a dictated report prior to its transcription.

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26
Q

Signatures

A

Minimum 1st initial and last name, title/credentials, or discipline. If two providers have the same last name and 1st initial full 1st name is required.

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27
Q

Countersignature

A

a form of authentication by an individual in addition to the signature by the original author. (ie. Dr signs in addition to intern…)

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28
Q

Telephone Order (T.O.)

A

Verbal order taken over the phone by a qualified professional from a physician. Must be authenticated within 24 hours.

29
Q

Voice Order (V.O.)

A

AKA: Verbal Order. A physician dictates the order in front of a responsible person. Documented only in emergencies only.

30
Q

Verbal Order

A

AKA: Voice Order

31
Q

Signature Legend

A

Document maintained by the health information department to identify the author by full signature when initials are used.

32
Q

Fax Signaures

A

Generally accepted except when expressly prohibited by state law.

33
Q

Uniform Business Records of Evidence Act

A

Addresses admissibility in court, states when a document with a fax signature is included in the patient record, the document containing the original signature should be retrievable.

34
Q

Electronic Signature

A

Generic term that refers to the various methods by which an electronic document can be authenticated. Accepted by facilities as allowed by federal and state regulations. Includes name at the end of an email, digitized image of a signature, PIN numbers, biometrics (ie fingerprint).

35
Q

ASTM

A

American Society for testing and Materials

36
Q

Signature Stamps

A

Stamp with the physicians signature. Not secure and with potential for abuse. Provider must sign a statement that only he will use the stamp. Medicare does not allow.

37
Q

The Joint Commission Do Not Use List

A

A list of abbreviations, acronyms, symbols that could be misinterpreted.

38
Q

Delinquent Record

A

A patient record that is not completed 30 days after the patient is discharged.

39
Q

Amending the Patient Record

A

Correcting documentation, must have a single line through the incorrect documentation so it is still legible, date, time, and signature, reason for correction, and the correct information as close as possible to the incorrect information

40
Q

Audit Trail

A

A list of all changes made to patient documentation

41
Q

Preadmission Testing

A

Labs, Xrays, EKG, etc.

42
Q

PAT

A

Preadmission Testing

43
Q

Provisional Diagnosis

A

a working, tentative, admission, preliminary diagnosis

44
Q

Nursing Assessment

A

Documents the patients history, current medications, and vitals signs on forms such as nursing notes, graphic charts, etc

45
Q

Reverse Chronological Order

A

the most current document is filed first in a section of the record

46
Q

Chronological Order

A

The oldest information filed first, in strict date order, allowing the chart to be read like a diary.

47
Q

Solo Practioner

A

A physician who practices alone (Dr. W!)

48
Q

Manual Record

A

A paper format of a patient record

49
Q

SOR

A

Source Oriented Record

50
Q

POR

A

Problem Oriented Record

51
Q

EMR

A

Electronic Medical Record

52
Q

mHealth

A

The use of wireless technology to enable better health care.

53
Q

Primary Source

A

Xrays, Scans, EKGs, etc.

54
Q

Secondary Source

A

information taken from the primary source, such as incident reports, indexes, committee minutes, etc.

55
Q

Incident Reports

A

NEVER FILED WITH THE PATIENT RECORD

56
Q

Incident Report

A

Information about a potentially compensable event

57
Q

PCE

A

Potentially compensable event

58
Q

POMR

A

Problem oriented medical record

59
Q

POR

A

Problem oriented record

60
Q

POR

A

Systematic method of documentation, compiled of four components: Database, Problem List, Initial Plan, Progress Notes

61
Q

SOAP

A

Subjective Objective Assessment Plan

62
Q

SOAP

A

(S) patient statement about how she feels; (O) Observation and test results (A) judgment, opinion, or evaluation made by health care providers (P) diagnostic, therapeutic, and educational plan to resolve the proglem

63
Q

CHEDDAR

A

Chief Complaint, History, Examination, Details, Drugs/Dosages, Assessment, Return Visit

64
Q

HPIP

A

History, Physical, Impression, Plan

65
Q

Digital Archive

A

Storage solution that consolidates electronic records on a computer server for management and retrieval

66
Q

Shadow Record

A

Paper records that contains copies of original records and is maintained separately from the primary records

67
Q

Information Capture Includes

A

handwriting, speaking, typing, touching a screen, pointing or clicking on records, phrases

68
Q

MRI

A

Medical Records Institute

69
Q

Information into medical record

A

typed, scanned, drop downs, touching a screen, phrases, etc.

Healthcare Documentation Essentials (6 decks)

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