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1
Q

Definition:
Includes medical staff–approved abbreviations and symbols (and their meanings) that can be documented in patient records. When more than one meaning exists for an abbreviation, the facility should choose one meaning or identify the context in which the abbreviation is to be documented; The Joint Commission standards have not explicitly required an approved list of abbreviations since 1991; however, its National Patient Safety Goals prohibit the use of “dangerous” abbreviations, acronyms, and symbols in patient records, which include those that could be misinterpreted (e.g., D/C could be interpreted as discharge or discontinue).

A

abbreviation list

2
Q

Definition:
Amending a patient record entry to clarify(avoid incorrect interpretation of information) or add additional information about previous documentation or to enter a late entry (out of sequence). Its purpose is to provide additional information, not to change documentation. The addendum should be documented as soon after the original entry as possible.

A

addendum

3
Q

Definition:

Demographic, socioeconomic, and financial information.

A

administrative data

4
Q

Definition:
State-mandated age of emancipation. Facilities must retain records for that state-mandated time period (such as 18 years) in addition to the retention law; also called age of majority.

A

age of consent

5
Q

Definition:
Provide behavioral health, home health, hospice, outpatient, skilled nursing, and other forms of care. Also serve as the documentation source for patient care information.

A

alternate care facilities

6
Q

Definition:
System for locating storage for patient records other than at the health care facility such as off-site storage, microfilm, or optical imaging.

A

alternative storage method

7
Q

Definition:
Correction of an incorrect patient record entry by the author of the original entry. To amend an entry in a manual patient record system, the provider should draw a single line through the incorrect information, document a reason for the error, and enter the correct information. To amend an entry in an electronic health record system, the basic principles for correcting documentation errors are followed, and the electronic health record system should store both the original and the corrected entry as well as a record of who documented each entry

A

amending the patient record

8
Q

Definition:

Records that are placed in storage and rarely accessed; also called inactive records.

A

archived records

9
Q

Definition:

Portion of the POR progress note that documents judgment, opinion, or evaluation made by the health care provider.

A

assessment (A)

10
Q

Definition:
Document intended to complement standards developed by other organizations and define a document structure for use by electronic signature mechanisms, the characteristics of an electronic signature process, minimum requirements for different electronic signature mechanisms, signature attributes for use with electronic signature mechanisms, acceptable electronic signature mechanisms and technologies, minimum requirements for user identification, access control, and other security requirements for electronic signatures, and technical details for all electronic signature mechanisms in sufficient detail to allow interoperability between systems supporting the same signature mechanism.

A

ASTM E 1762–Standard Guide for Authentication of Healthcare-Information

11
Q

Definition:
List of all changes made to patient documentation in an electronic health record system, including all transactions and activities, date, time, and user who performed the transaction.

A

audit trail

12
Q

Definition:

A patient record entry signed by the author (e.g., provider).

A

authentication

13
Q

Definition:
Authentication of a dictated report by a provider prior to its transcription. This practice is not consistent with proper authentication procedures because providers must authenticate the document after it was transcribed.

A

auto-authentication

14
Q

Definition:

Missing reports, documentation, and signatures as determined upon patient record analysis.

A

chart deficiencies

15
Q

Definition:
Oldest information is filed first in a section of a discharged patient record. With integrated records, the order of reports is in strict date order, allowing the record to read like a diary.

A

chronological date order

16
Q

Definition:
Health information obtained throughout treatment and care of patient. Includes health care information obtained about a patient’s care and treatment, which is documented on numerous forms in the patient record.

A

clinical data

17
Q

Definition:
Authentication performed by an individual (e.g., attending physician) in addition to the signature by the original author of an entry (e.g., resident).

A

countersignature

18
Q

Definition:
Documentation in the POR of a minimum set of data collected on every patient, such as chief complaint; present conditions and diagnoses; social data; past, personal, medical, and social history; review of systems; physical examination; and baseline laboratory data. Serves as an overview of patient information.

A

database

19
Q

Definition:
Form or software completed by the health information analysis clerk and attached to the patient record, which is used to record or enter chart deficiencies that are noted in the patient’s record (e.g., missing physician signatures).

A

deficiency slip

20
Q

Definition:

Records that remain incomplete 30 days after patient discharge (The Joint Commission standard).

A

delinquent records

21
Q

Definition:

Statistic calculated by dividing total number of delinquent records by the number of discharges in the period.

A

delinquent record rate

22
Q

Definition:
Patient identification information collected according to facility policy that includes the patient’s name and other information, such as date of birth, place of birth, mother’s maiden name, and social security number.

A

demographic data

23
Q

Definition:

Category of POR’s initial plan that documents the patient’s condition and management of the condition.

A

diagnostic/management plans

24
Q

Definition:
Storage solution that consolidates electronic records on a computer server for management and retrieval.
Next Card

A

digital archive

25
Q

Definition:
Automated record system that contains a collection of information documented by a number of providers at different facilities regarding one patient; has the ability to link patient information created at different locations according to a unique patient identifier; provides access to complete and accurate health problems, status, and treatment data; and contains alerts (e.g., drug interaction) and reminders (e.g., prescription renewal notice) for health care providers.

A

electronic health records (EHR)

26
Q

Definition:
Documents services received by a patient who has not been admitted to the hospital overnight, and includes ancillary services, emergency department services, and outpatient (or ambulatory) surgery; also called hospital ambulatory care record.

A

hospital ambulatory care record

27
Q

Definition:

Documents the care and treatment received by a patient admitted to the hospital.

A

hospital inpatient record

28
Q

Definition:
Documents services received by a patient who has not been admitted to the hospital overnight, and includes ancillary services, emergency department services, and outpatient (or ambulatory) surgery; also called hospital ambulatory care record.

A

hospital outpatient record

29
Q

Definition:

Records that are placed in storage and rarely accessed; also called inactive records.

A

inactive records

30
Q

Definition:
Collects information about a potentially compensable event (PCE); it is generated on patients and visits and provides a summary of the PCE in case the patient or visit files a lawsuit.

A

incident report

31
Q

Definition:

Contains clinical information created by researchers, typically in academic medical centers.

A

independent database

32
Q

Definition:
Process of recording representations of human thought, perceptions, or actions in documenting patient care, as well as device-generated information that is gathered and/or computed about a patient as part of health care.

A

information capture

33
Q

Definition:
Documentation in the POR that describes actions that will be taken to learn more about the patient’s condition and to treat and educate the patient according to three categories: diagnostic/management plans, therapeutic plans, and patient education plans.

A

initial plan

34
Q

Definition:
Patient record format that usually arranges reports in strict chronological date order. The record could also be arranged in reverse date order.

A

integrated record

35
Q

Definition:

Destruction of electronic records by altering magnetic fields on a computer medium.

A

magnetic degaussing

36
Q

Definition:
Maintenance of patient records in paper format. It includes the source oriented record (SOR), problem oriented record (POR), and integrated record.

A

manual record

37
Q

Definition:
Refers to use of wireless technology to enable health care professionals to make better-quality decisions while reducing the cost of care and improving convenience to caregivers.

A

mHealth

38
Q

Definition:
Photographic process that records the original paper record on film, with the film image appearing similar to a photograph negative.

A

microfilm

39
Q

Definition:
Documents patient’s history, current medications, and vital signs on a variety of nursing forms, including nurses notes and graphic charts.

A

nursing assessment

40
Q

Definition:
Portion of the POR progress note that documents observations about the patient, such as physical findings or lab or x-ray results (e.g., chest x-ray negative).

A

objective (O)

41
Q

Definition:

Location separate from the facility used to store records; also called remote storage.

A

off-site storage

42
Q

Definition:

Category of POR’s initial plan that documents patient teaching about conditions and treatments.

A

patient education plans

43
Q

Definition:
Serves as the business record for a patient encounter, contains documentation of all health care services provided to a patient, and is a repository of information that includes demographic data, and documentation to support diagnoses, justify treatment, and record treatment results.

A

patient record

44
Q

Definition:
Person who has legal responsibility for the patient and signs an admission consent form to document consent to treatment.

A

patient’s representative

45
Q

Definition:
Documents patient health care services received in a physician’s office. Should contain patient registration information, a problem list, a medication record, progress notes (including patient’s history and physical examination), and results of ancillary reports.

A

physician office record

46
Q

Definition:

Portion of the POR progress note that documents diagnostic, therapeutic, and educational plans to resolve the problems.

A

plan (P)

47
Q

Definition:

An accident or medical error that results in personal injury or loss of property.

A

potentially compensable event (PCE)

48
Q

Definition:
Incorporates patient registration, testing, and other services into one visit prior to inpatient admission (or scheduled outpatient surgery) with the results incorporated into the patient’s record.

A

preadmission testing (PAT)

49
Q

Definition:
Records that document patient care provided by health care professionals and include original patient record, x-rays, scans, EKGs, and other documents of clinical findings.

A

primary sources

50
Q

Definition:
Documentation in the POR that acts as a table of contents for the patient record because it is filed at the beginning of the record and contains a list of the patient’s problems. Each problem is numbered, which helps to index documentation throughout the record.

A

problem list

51
Q

Definition:
Systematic method of documentation, which consists of four components: database, problem list, initial plan, and progress notes. Also called problem oriented medical record (POMR).

A

problem oriented medical record (POMR)

52
Q

Definition:
Systematic method of documentation, which consists of four components: database, problem list, initial plan, and progress notes. Also called problem oriented medical record (POMR).

A

problem oriented record (POR)

53
Q

Definition:
Working, tentative, admission, and preliminary diagnosis obtained from the attending physician; it is the diagnosis upon which inpatient care is initially based.

A

provisional diagnosis

54
Q

Definition:
Remove inactive paper-based records from a file system for the purpose of converting them to microfilm or optical disk or destroying them.

A

purge

55
Q

Definition:
Paper records are usually dissolved in acid, incinerated (burned), pulped or pulverized (crushing into powder), or shredded.

A

record destruction methods

56
Q

Definition:
Outlines patient information that will be maintained, time period for retention, and manner in which information will be stored. Records are stored on paper, microfilm, magnetic tape, optical disk, or as part of an electronic (or computer) system.

A

record retention schedule

57
Q

Definition:

Location separate from the facility used to store records; also called remote storage.

A

remote storage

58
Q

Definition:
Consists of formatting and/or structuring captured information. A process of analyzing, organizing, and presenting recorded patient information for authentication and inclusion in the patient’s health care record.

A

report generation

59
Q

Definition:

Length of time a facility will maintain an archived record, based on federal and state laws.

A

retention period

60
Q

Definition:

Most current document is filed first in a section of the inpatient record.

A

reverse chronological date order

61
Q

Definition:
Patient information that contains data abstracted (selected) from primary sources of patient information such as indexes and registers, committee minutes, and incident reports.

A

secondary sources

62
Q

Definition:

Each source of data in the inpatient record has a section that is labeled.

A

sectionalized record

63
Q

Definition:

Paper record that contains copies of original records and is maintained separately from the primary record.

A

shadow record

64
Q

Definition:
Document maintained by the health information department to identify the author by full signature when initials are used to authenticate entries. Initials are typically used to authenticate entries on nursing flow sheets, such as medication administration records.

A

signature legend

65
Q

Definition:
When authorized for use in a facility, the provider whose signature the stamp represents must sign a statement that the provider alone will use the stamp to authenticate documents. The statement is maintained on file in the facility’s administrative offices.

A

signature stamp

66
Q

Definition:

Organizations that do not have physician partners or employment affiliations with other practice organizations.

A

solo practitioner

67
Q

Definition:

Traditional patient record format that maintains reports according to source of documentation.

A

source oriented record (SOR)

68
Q

Definition:

Software that translates speech into text; sometimes called “talk to text.”

A

speech recognition software

69
Q

Definition:
Refers to the time period after which a lawsuit cannot be filed. Statutes of limitations vary state to state, and the statute of limitations for medical malpractice cases varies from 1 to 3 years.

A

statute of limitations

70
Q

Definition:
Portion of the POR progress note that documents the patient’s statement about how he or she feels, including symptomatic information.

A

subjective (S)

71
Q

Definition:

A verbal order taken over the telephone by a qualified professional (e.g., registered nurse) from a physician.

A

telephone order (T.O.)

72
Q

Definition:
Category of POR’s initial plan that specifies medications, goals, procedures, therapies, and treatments used to care for the patient.

A

therapeutic plans

73
Q

Definition:
Documented when a patient is being transferred to another facility. It summarizes the reason for admission, current diagnoses and medical information, and reason for transfer.

A

transfer note

74
Q

Definition:
Physician dictates an order in the presence of a responsible person; this is no longer accepted as standard practice by health care facilities and is documented in emergencies only.

A

voice order (V.O.)

75
Q

Definition:

Software that translates speech into text; sometimes called “talk to text.”.

A

voice recognition software

76
Q

Definition:
Automated record system that contains a collection of information documented by a number of providers at different facilities regarding one patient; has the ability to link patient information created at different locations according to a unique patient identifier; provides access to complete and accurate health problems, status, and treatment data; and contains alerts (e.g., drug interaction) and reminders (e.g., prescription renewal notice) for health care providers.

A

Electronic health records (EHRs)

77
Q

Definition:
Document intended to complement standards developed by other organizations and define a document structure for use by electronic signature mechanisms, the characteristics of an electronic signature process, minimum requirements for different electronic signature mechanisms, signature attributes for use with electronic signature mechanisms, acceptable electronic signature mechanisms and technologies, minimum requirements for user identification, access control, and other security requirements for electronic signatures, and technical details for all electronic signature mechanisms in sufficient detail to allow interoperability between systems supporting the same signature mechanism.

A

ASTM E 1762–Standard Guide for Authentication of Healthcare Information

78
Q

Definition:
When authorized for use in a facility, the provider whose signature the stamp represents must sign a statement that the provider alone will use the stamp to authenticate documents. The statement is maintained on file in the facility’s administrative offices.

A

signature stamps