Medical records Ch 14,15,16

Of or relating to systems made up of combinations of letters and numbers.

arranged in order according to the alphabet

designated by or expressed in numbers

a chronologic file used as a reminder

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.

A method of filing whereby one report is laid on top of the older report, resembling the shingles of a roof.

a heading title, or subtitle under which records are filed.

A formal examination of an organization’s or individual’s accounts or financial situation; a methodic examination and review.

Intentionally putting off doing something that should be done

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

commonly occurring; widely accepted or practiced

medical informatics
study of medical computing

any of a set of physical properties, the values of which determine characteristics of behavior.

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.

Encoded; converted from one system of communication to another.

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.

containing or characterized by error or assumption

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.

(medicine) a reason that makes it inadvisable to prescribe a particular drug or employ a particular procedure or treatment

Fundamentally different and often incongruous elements; elements that are markedly distinct in quality or character.

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