Wilson Ch 8 Flashcards
Charting
The process of tabulating clinical information on a graphic form
Chart
A form or graphic uses as a component of a patients permanent health record
Encryption
Translation of computerized data into a secret code; most effective way to achieve data security; need key or password to translate cipher text
Forensic
Pertaining to or used in legal proceedings
Forensic dentistry
Refers to the use of dental records or oral health data to identify individuals for legal proceedings
Malpractice
Professional negligence; a deviation from acceptable standards of care that causes injury to a patient
Patient record
Written document that contains information identifying an individual patient such as a patients name, address, and phone number, as well as information related to that particular patients care such as health history information, dental charting items, treatment dates, and treatment codes.
Electronic record
In a computerized database management system, a record is a complete set if information
Sign
Objective, observable evidence of an illness or disorder, a physical manifestation of a disorder that is apparent to a trained healthcare provider and sometimes to the patient
Symptom
Any change in the body or its function that is perceived by the patient, the subjective experience of a disorder or disease
Triage
Screening and classification of individuals in order to make optimal use of treatment resources; sorting and allocating relative priority for patient treatment needs
Unique identifier
Secret name or password used by an individual to access computerized information that is not available to others who do not have permission to access the information