Medical records Ch 14,15,16 – Flashcards

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alphanumeric
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Of or relating to systems made up of combinations of letters and numbers.
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alphabetic
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arranged in order according to the alphabet
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numeric
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designated by or expressed in numbers
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tickler
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a chronologic file used as a reminder
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augment
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to enlarge; to increase in amount or intensity
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subjective information
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information gained by questioning the patient or taking it from a form
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objective information
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information that is gathered by watching or observation of a patient.
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shingling
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A method of filing whereby one report is laid on top of the older report, resembling the shingles of a roof.
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caption
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a heading title, or subtitle under which records are filed.
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audit
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A formal examination of an organization's or individual's accounts or financial situation; a methodic examination and review.
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procrastination
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Intentionally putting off doing something that should be done
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vested
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Granted or endowed with a particular authority, right, or property; to have a special interest in
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provisional diagnosis
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A temporary diagnosis made before all test results have been received.
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retention schedule
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A method or plan for retaining or keeping medical records, and their movement from active, to inactive, to closed filing.
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aggregate of electronic health information
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documents from two or more different health facilities
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electronic medical record EMR
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"An electronic record of health-related information on an individual that can be created, gathered, managed, and consulted by authorized clinicians and staff within a single health care organization"
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electronic health record EHR
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an electronic record of health-related information about a patient that conforms a nationally recognized interoperability standards and that can be created, managed, consulted by authorized clinicians and staff from more than one healthcare organization
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prevalent
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commonly occurring; widely accepted or practiced
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medical informatics
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study of medical computing
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parameter
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any of a set of physical properties, the values of which determine characteristics of behavior.
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authenticate
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prove; with regard to medical records, it applies to a signature, initials, or computer keystroke by the maker of the record to verify that the record is correct.
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adverse event
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injury caused by medical management rather than the underlying conditions of the patient. These may or may not be preventable. If preventable, these are called Preventable Adverse Drug Events.
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encrypted
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Encoded; converted from one system of communication to another.
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standards
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Models or examples established by authority, custom. or general consent; something set up and established by authority as a rule for the measure of quantity, weight, extent, value, or quality.
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erroneous
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containing or characterized by error or assumption
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transpose
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reverse the order or position of
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quality assurance
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Activities designed to increase the quality of a product or service through process or system changes that increase efficiency or effectiveness.
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contraindication
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(medicine) a reason that makes it inadvisable to prescribe a particular drug or employ a particular procedure or treatment
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disparities
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Fundamentally different and often incongruous elements; elements that are markedly distinct in quality or character.
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circumvent
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to get around; to bypass
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sentinel events
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an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof
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near miss
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Medical error that is almost made but caught before it happens
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