Medical records Ch 14,15,16

alphanumeric
Of or relating to systems made up of combinations of letters and numbers.
alphabetic
arranged in order according to the alphabet
numeric
designated by or expressed in numbers
tickler
a chronologic file used as a reminder
augment
to enlarge; to increase in amount or intensity
subjective information
information gained by questioning the patient or taking it from a form
objective information
information that is gathered by watching or observation of a patient.
shingling
A method of filing whereby one report is laid on top of the older report, resembling the shingles of a roof.
caption
a heading title, or subtitle under which records are filed.
audit
A formal examination of an organization’s or individual’s accounts or financial situation; a methodic examination and review.
procrastination
Intentionally putting off doing something that should be done
vested
Granted or endowed with a particular authority, right, or property; to have a special interest in
provisional diagnosis
A temporary diagnosis made before all test results have been received.
retention schedule
A method or plan for retaining or keeping medical records, and their movement from active, to inactive, to closed filing.
aggregate of electronic health information
documents from two or more different health facilities
electronic medical record EMR
“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”
electronic health record EHR
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
prevalent
commonly occurring; widely accepted or practiced
medical informatics
study of medical computing
parameter
any of a set of physical properties, the values of which determine characteristics of behavior.
authenticate
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.
adverse event
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.
encrypted
Encoded; converted from one system of communication to another.
standards
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.
erroneous
containing or characterized by error or assumption
transpose
reverse the order or position of
quality assurance
Activities designed to increase the quality of a product or service through process or system changes that increase efficiency or effectiveness.
contraindication
(medicine) a reason that makes it inadvisable to prescribe a particular drug or employ a particular procedure or treatment
disparities
Fundamentally different and often incongruous elements; elements that are markedly distinct in quality or character.
circumvent
to get around; to bypass
sentinel events
an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof
near miss
Medical error that is almost made but caught before it happens