Medical records Ch 14,15,16 – Flashcards
Unlock all answers in this set
Unlock answersquestion
alphanumeric
answer
Of or relating to systems made up of combinations of letters and numbers.
question
alphabetic
answer
arranged in order according to the alphabet
question
numeric
answer
designated by or expressed in numbers
question
tickler
answer
a chronologic file used as a reminder
question
augment
answer
to enlarge; to increase in amount or intensity
question
subjective information
answer
information gained by questioning the patient or taking it from a form
question
objective information
answer
information that is gathered by watching or observation of a patient.
question
shingling
answer
A method of filing whereby one report is laid on top of the older report, resembling the shingles of a roof.
question
caption
answer
a heading title, or subtitle under which records are filed.
question
audit
answer
A formal examination of an organization's or individual's accounts or financial situation; a methodic examination and review.
question
procrastination
answer
Intentionally putting off doing something that should be done
question
vested
answer
Granted or endowed with a particular authority, right, or property; to have a special interest in
question
provisional diagnosis
answer
A temporary diagnosis made before all test results have been received.
question
retention schedule
answer
A method or plan for retaining or keeping medical records, and their movement from active, to inactive, to closed filing.
question
aggregate of electronic health information
answer
documents from two or more different health facilities
question
electronic medical record EMR
answer
"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"
question
electronic health record EHR
answer
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
question
prevalent
answer
commonly occurring; widely accepted or practiced
question
medical informatics
answer
study of medical computing
question
parameter
answer
any of a set of physical properties, the values of which determine characteristics of behavior.
question
authenticate
answer
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.
question
adverse event
answer
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.
question
encrypted
answer
Encoded; converted from one system of communication to another.
question
standards
answer
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.
question
erroneous
answer
containing or characterized by error or assumption
question
transpose
answer
reverse the order or position of
question
quality assurance
answer
Activities designed to increase the quality of a product or service through process or system changes that increase efficiency or effectiveness.
question
contraindication
answer
(medicine) a reason that makes it inadvisable to prescribe a particular drug or employ a particular procedure or treatment
question
disparities
answer
Fundamentally different and often incongruous elements; elements that are markedly distinct in quality or character.
question
circumvent
answer
to get around; to bypass
question
sentinel events
answer
an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof
question
near miss
answer
Medical error that is almost made but caught before it happens
