Chapter 4 - Health Record Content And Documentation Flashcards
Advance directive
A legal, written document that describes the patient’s preferences regarding future healthcare or stipulates the person who is authorized to make medical decisions in the event the patient is incapable of communicating his or her preferences
Authentication
As amended by HITECH, except as otherwise specified, a covered entity may not use or disclose protected health information without an authorization that is valid under section 164.508. 2. When a covered entity obtains or receives a valid authorization for its use or disclosure of protected health information, such use or disclosure must be consistent with the authorization (45 CFR 164.508 2013)
Bylaws
Operating documents that describe the rules and regulations under which a healthcare organization operates
Care path
A care-planning tool similar to a clinical practice guideline that has a multidisciplinary focus emphasizing the coordination of clinical services
Case manager
A nurse, doctor, or social worker who arranges all services that are needed to give proper healthcare to a patient or group of patients
Charting by exception
A system of health record documentation in which progress notes focus on abnormal events and describe any interventions that were ordered and the patient’s response
Closed record
A health record that has been closed following analysis to ensure all documentation components are met, for example, signatures and dictated reports 2. Documentation or a note that has been closed due to system requirements or after a defined period of time
Closed-record review
A review of records after a patient has been discharged from the organization or treatment has been terminated
Computerized provider order entry (CPOE) system
Electronic prescribing systems that allow physicians to write prescriptions and transmit them electronically. These systems usually contain error prevention software that provides the user with prompts that warn against the possibility of drug interaction, allergy, or overdose and other relevant information
Concurrent analysis
A review of the health record while the patient is still hospitalized or under treatment
Consent
A patient’s acknowledgement that he or she understands a proposed intervention, including that intervention’s risks, benefits, and alternatives 2. The document signed by the patient that indicates agreement that protected health information (PHI) can be disclosed
Consultation
Opinions of physicians with specialty training beyond general board certification such as oncologists, cardiologists, or dermatologists
Delinquent health record
An incomplete record not finished or made complete within the time frame determined by the medical staff of the facility
Digital dictation
The process by which voice sounds are recorded and converted into a digital format
Discharge summary
A summary of the resident’s stay at a healthcare facility that is used along with the post-discharge plan of care to provide continuity of care upon discharge from the facility
Disposition
A description of that patient’s status at discharge
Do not resuscitate (DNR) order
An order written by the treating physician stating that in the event the patient suffers cardiac or pulmonary arrest, cardiopulmonary resuscitation should not be attempted
Durable power of attorney
A power of attorney that remains in effect even after the principal is incapacitated; some are drafted so that they only take effect when the principal becomes incapacitated
Electronic signature
A generic, technology-neutral term for the various ways that an electronic record can be signed, such as a digitized image of a signature, a name typed at the end of an email message by the sender, a biometric identifier, a secret code or PIN, or a digital signature
