Chapter 6 Flashcards
Admission, Discharge & Transfer (ADT) System
Electronic tracking of the registrations, admissions, discharges, and transfers occurring in a hospital at any given time. It is sometimes referred to as RADT (“R” for registration).
Advance Directive
A document listing a patient’s wishes, should he or she be unable to make decisions for himself or herself or the naming of an individual who is authorized to do so.
Apgar Score
A newborn assessment done at one minute and at 5 minutes after birth to assess the newborns respiratory function, heartrate, muscle tone, reflexes and skin color.
Attending Physician
The physician responsible for the care of the patient while hospitalized.
Autopsy
An examination performed after death to examine organs and tissue in order to determine cause of death.
Barcode
A machine-readable code consisting of vertical parallel bars and white space, which is converted to identification. Every scanned document contains a barcode identifying the patient and encounter to which the document belongs and matches that document to the correct patient and encounter within the EHR.
Charting By Exception
Documentation based on occurrences that are out of the norm or documentation of complaints voiced by patients. Examples include a patient stating that his pain is worse that it had been, the fact that a patient was combatitve, adn the fact that a patient walked to the bathroom without calling for assistance, even though he was to be non-ambulatory.
Claims Data
Billing codes that physicians, pharmacies, hospitals and other healthcare providers submit to payers. These data have the benefit of following a relatively consistent format and of using a standard set of ICD 9/10 codes.
Computerized Physician Order Entry (CPOE)
Electronic means of ordering tests and medications that also provides clinical advice about the drug, the dosage, and any contraindications.
Durable Medical Equipment (DME)
Medical equipment meant to be used for long periods, such as hospital beds, hearing aids, orthotics and prostheses.
History of Present Illness
The symptoms or circumstances leading the patient to seek medical intervention.
Hospitalist
A physician employed by a hospital, and is typically a board certified internist or family practioner, responsible for admitting patients, following and assessing patients as needed, and writing orders as necessary.
Interface
A program that allows two or more similar or different devices to communicate and be interoperable.
Medication Administration Record (MAR)
Documentation of each medication administered, the dosage, the route, the time and date administered, and the name of the person administering the medication.
Nursing Assessment
The documentation of a nursing interview and exam performed immediately or shortly after admission that details information such as; means of admission (by wheelchair, ambulatory, etc.), reason for admission, events leading to admission, presence of chronic conditions, current medications, drug allergies, person to contact in case of emergency, and whether the patient can perfrom typical activities of daily living.
Observation
A patient status used when the patients condition does not warrant an inpatient level of care but does require observation by medical personnel. Observation typically lasts from 24 to no more than 48 hours.
Pathologist
A physician whose specialty is dealing with the analysis of a tissue sample to establish a diagnosis.
Patient Rights Acknowledgement
A listing of guarantees that a patient should expect, including the right to privacy, the right to make one’s own medical decisions, the right to treatment, and the right to be treated fairly.
Point of Care
The physical location where a healthcare professional delivers services to a patient.
Post-Anesthetic Care Unit (PACU)
The unit to which a patient is transferred following surgery for monitoring of vital signs and condition post surgery.
Property and Valuables Inventory
A listing of all the personal property the patient had on his or her person when arriving in the hospital room.
Review of Systems (ROS)
A body system - by body system set of questions asked of a patient regarding symptoms he or she may be experiencing.
Template
A preformatted document found in software, that prompts structured responses in the EHR.
Verbal Order
An order given to a nurse either in person or over the phone.
