Chapter 6 - The Active Health Record in Acute Care Settings Flashcards
Patient rights acknowledgement
P. 146
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 refuse treatment, and the right to be treated fairly.
Nursing assessment
P. 147
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.) reasons for admission, events leading to admission, presence of chronic conditions, current medications, drug allergies, person to contact in case of an emergency, and whether the patient can perform typical activities of daily living.
Advance directive
P. 147
A document listing a patient’s wishes, should he or she be unable to make decisions for him or herself, or the naming of an individual who is authorized to do so.
Property and valuables inventory
p. 147
a listing of all the personal property (clothing, jewelry, prosthetic devices, wallet, money, etc.) the patient had on his or her person when arriving in the hospital room.
Charting by exception
P. 148
Documentation based on occurrences that are out of the norm or documentation of complaints voiced by the patient.
•Examples include a patient stating that his pain is worse than it had been, the fact that the a patient was combative, and the fact that a patient walked to the bathroom without calling for assistance, even though he was to be non-ambulatory.
Template
P. 148
A preformatted document, found in software, that prompts structured responses in the EHR.
Medication administration record (MAR)
P. 148
Documentation of each medication administered, the dosage, the route of administration, the time and date administered, and the name of the person administering the medication.
Attending physician
P. 149
The Physician responsible for the care of the patient while hospitalized.
Hospitalist
P. 149
A physician, employed by a hospital and is typically a board-certified internist or family practitioner, responsible for admitting patients, following and assessing patients as needed, and writing orders as necessary.
Verbal order
P. 149
In order given to a nurse either in person or over the phone, then later authenticated by the physician or physician extender.
Observation
P. 149
A patient status used when the patient’s condition does not warrant in inpatient level of care but does require observation by medical personnel. Observation typically lasts from 24 hours to know more than 48 hours.
History of present illness (HPI)
P. 151
The symptoms or circumstances leading the patient to seek medical intervention.
Review of systems (ROS)
P. 151
A system-by-system set of questions asked of a patient regarding symptoms he or she may be experiencing.
Pathologist
P. 152
A physician whose specialty is dealing with the analysis of a tissue sample to establish a diagnosis.
Autopsy
P. 152
An examination performed after death to examine organs and tissue in order to determine cause of death.
Post-anesthesia Care Unit (PACU)
P. 153
The unit to which a patient is transferred following surgery for monitoring of vital signs and condition post-surgery.
Durable medical equipment (DME)
P. 156
Medical equipment meant to be used for long periods. Such as hospital beds, hearing aids, orthotics, and processes.
Apgar score
P. 156
A newborn assessment done at one minute and five minutes after birth to assess the newborns respiratory function, heart rate, muscle tone, reflexes, and skin color.
Computerized physician order entry (CPOE)
P. 158
Electronic means of ordering tests and medications that also provides clinical advice about the drug, the dosage, and any contraindications.
Picture archiving and communication system (PACS)
P. 159
Digitizes Radiology film into computer images. X-ray film takes a great deal of valuable floor space for storage, disposal is expensive, and duplication is time-consuming and labor-intensive, should films be needed by another physician or facility. With a PACS, images are stored on an optical disc and easily duplicated or transferred to another provider of care
Admission, discharge, and transfer ( ADT) system
P. 162
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”).
Patient census
P. 162
The number of inpatients occupying beds at any given time.
Bar code
P. 163
A machine readable code consisting of vertical parallel bars and white space. Every scan document contains a bar code identifying the patient and the encounter to which the document belongs. The bar code then matches that document to the correct location and encounter within the EHR.
Point of care
P. 164
The physical location where a healthcare professional delivers services to a patient.
Interface
P. 166
A program that allows two or more similar or different devices to communicate and be interoperable.
Claims data
P. 166
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 10 codes.
