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Flashcards in Healthcare Documentation Deck (7)
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1
Q

HIM professional

A

health information management

2
Q

Consistency

A

uniformity of content / vocab standards. No slang, ambiguous language, only standard abbreviations

3
Q

Qualitative analysis

A

review of med record ensures standards are met and determine accuracy of record documentation

4
Q

Quantitative analysis

A

review of med record to determine completeness

5
Q

Audit: concurrent review

A

Review of the medical record carried out while the patient is actively receiving care. HIM professionals and document authors review the records as they are created and compiled. The benefit of this type of review is that documentation issues can be identified at the time of patient care and rectified (if necessary) in a timely manner.

6
Q

Audit: occurrence screening

A

Review technique of medical records of current and discharged patients with the goal of identifying events which could potentially lead to compensation by the healthcare provider. Risk management audit. The reviewer looks for accidents, omissions, or medical errors which resulted or could potentially result in a personal injury or loss of property. Occurrences include instances when the wrong surgery was performed or an informed consent for a procedure was not obtained.

7
Q

Audit: retrospective review

A

Review of the medical record after the patient has been discharged, but is still very useful for identifying and addressing weaknesses in documentation processes, areas where staff need additional training, and, where appropriate, addressing deficiencies in individual records.