Documentation, Confidentiality, & Ethics Flashcards
1
Q
healthcare documentation process
A
The process by which a patient’s medical record is created and stored.
2
Q
medical record
A
The details of a patient’s healthcare visit(s). Including demographic 7 personal information, reason for admission, & usually some patient-supplied information.
3
Q
HIM
A
Health Information Management
4
Q
EHR
A
electronic health record
5
Q
SNOMED
A
systematized nomenclature of medicine
6
Q
Health Information Exchange
A
The use of information technology to improve the quality, safety, efficiency, and confidentiality of healthcare through simultaneous access to patient health information by multiple healthcare providers.
