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
Emergency Medical Treatment and Active Labor Act (EMTALA)
A 1986 law enacted as part of the Consolidated Omnibus Reconciliation Act largely to combat “patient dumping”–the transferring, discharging, or refusal to treat indigent emergency department patients because of their inability to pay (Public Law 99-272 1986)
History
A summary of the patient’s illness from his or her point of view
Hybrid record
A combination of paper and electronic records; a health record that includes both paper and electronic elements
Informed consent
A legal term referring to a patient’s right to make his or her own treatment decisions based on the knowledge of the treatment to be administered or the procedure to be performed 2. An individual’s voluntary agreement to participate in research or to undergo a diagnostic, therapeutic, or preventative medical procedure
Integrated health record
A system of health record organization in which all the paper forms are arranged in strict chronological order and mixed with forms created by different departments
Joint Commission
An independent, not-for-profit organization, the Joint Commission accredits and certifies more than 20,000 healthcare organizations and programs in the United States. Joint Commission accreditation and certification is recognized nationwide as a symbol of quality that reflects an organization’s commitment to meeting certain performance standards
Longitudinal health record
A permanent, coordinated patient record of significant information listed in chronological order and maintained across time, ideally from birth to death
Master patient index (MPI)
A patient-identifying directory referencing all patients related to an organization and which also serves as a link to the patient record or information, facilitates patient identification, and assists in maintaining a longitudinal patient record from birth to death
Medicare
A federally funded health program established in 1965 to assist with the medical care costs of Americans 65 years of age and older as well as other individuals entitled to Social Security benefits owing to their disabilities
Medication administration record (MAR)
The records used to document the date and t ime each dose and type of medication is administered to a patient
Notice of Privacy Practices
As amended by HITECH, a statement (mandated by the HIPAA Privacy Rule) issued by a healthcare organization that informs individuals of the uses and discloses of patient-identifiable health information that may be made by the organization, as well as the individual’s rights and the organization’s legal duties with respect to that information (45 CFR 164.520 2013)
Open-record review
A review of the health records of patients currently in the hospital or under active treatment; part of the Joint Commission survey process
Optical imaging technology
The process by which information is scanned onto optical disks
Overlap
Situation in which a patient is issued more than one medical record number from an organization with multiple facilities
Overlay
Situation in which a patient is issued a medical record number that has been previously issued to a different patient
Patient/member web portals
Portal that allows patients to pay their bills online and to securely view all or portions of their provider-based, electronic health record, such as current medical conditions, medications, allergies, and tests results
Personal health record (PHR)
An electronic or paper health record maintained and updated by an individual for himself or herself; a tool that individuals can use to collect, track, and share past and current information about their health or the health of someone in their care
Problem-oriented medical record
A patient record in which clinical problems are defined and documented individually
Progress notes
The documentation of a patient’s care, treatment, and therapeutic response, which is entered into the health record by each of the clinical professionals involved in a patient’s care, including nurses, physicians, therapists, and social workers
Qualitative analysis
A review of the health record to ensure that standards are met and to determine the adequacy of entries documenting the quality of care
Quantitative analysis
A review of the health record to determine its completeness and accuracy
Retention
Mechanisms for storing records, providing for timely retrieval, and establishing the length of t ime that various types of records will be retained by the healthcare organization 2. The ability to keep valuable employees from employment elsewhere
Scanning
The process by which a document is read into an optical imaging system
Serial-unit numbering system
In this system, the patient is issued a different number for each admission or encounter for care and the records of past episodes of care are brought forward to be filed under the last number issued
Source-oriented health record
A system of health record organization in which information is arranged according to the patient care department that provided the care
Straight numeric filing system
In this system, records are filed in numerical order according to the number assigned
Terminal-digit filing system
Records are filed according to a three-part number made up of two-digit pairs; the basic terminal-digit filing system contains 100,000 divisions, made up of 100 sections ranging from 00 to 99 with 100 divisions within each section ranging from 00 to 99
Unique identifier
A combination of numbers or alphanumeric characters assigned to a particular patient
Unit numbering system
A health record identification system in which the patient receives a unique medical record number at the time of the first encounter that is used for all subsequent encounters
Voice recognition technology
A method of encoding speech signals that do not require speaker pauses (but uses pauses when they are present) and of interpreting at least some of the signals’ content as words or the intent of the speaker
