Paper-Based and Hybrid Health Records
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Accreditation Association for Ambulatory Health Care (AAAHC)
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Association that requires that the history and physical examination, laboratory reports, radiology reports, operative reports, and consultations be signed in a timely manner
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Administrative Information
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Information used for administrative and healthcare operations purposes such as billing and quality oversight
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Advance Directive
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A legal, written document that describes the patient's preferences regarding future healthcare or stipulates the person authorized to make medical decisions in the event the patient is incapable of communicating his or her preferences
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American College of Surgeons (ACS)
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The scientific and educational association of surgeons formed to improve the quality of surgical care by setting high standards for surgical education and practice
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Association of Healthcare Documentation Integrity (AHDI)
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Formerly the American Association for Medical Transcription (AAMT), the AHDI has a model curriculum for formal educational programs that includes the study of medical terminology, anatomy and physiology, medical science, operative procedures, instruments, supplies, laboratory values, reference use and research techniques, and English grammar
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Authentication
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1. The process of identifying the source of health record entries by attaching a handwritten signature, the author's initials, or an electronic signature. 2. Proof of authorship that ensures, as much as possible, that log-ins and messages from a user originate from an authorized source
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Authorization
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The granting or permission to disclose confidential information; as defined in terms of the HIPAA privacy rule, an individual's formal, written permission to use or disclose his or her personally identifiable health information for purposes other than treatment, payment, or healthcare operations
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Autoauthentication
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A procedure that allows dictated reports to be considered automatically signed unless the health information management department is notified of needed revisions within a certain time limit
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Bar Coding
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A method of encoding data that consists of parallel arrangements of dark elements, referred to as bars, and light elements, referred to as spaces, and interpreting the data for automatic identification and data collection purposes
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Bylaws
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Operating documents that describe the rules and regulations under which a healthcare organization operates
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Care Path
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A care-planning tool similar to a clinical practice guideline that has a multidisciplinary focus emphasizing the coordination of clinical services
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Case Manager
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1. A professional nurse who coordinates the daily progress of a patient population by assessing needs, developing goals, individualizing plans of care on an ongoing basis, and evaluating overall progress 2. A medical professional (usually a nurse or a social worker) who reviews cases to determine the necessity of care and to advice providers on payer's utilization restrictions
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Certified Medical Transcriptionist (CMT)
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A certification that is granted upon successful completion of an examination
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Chart Tracking
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A system that identifies the current location of a record or information
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Charting by Exception
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A method of charting only abnormal or unusual findings or deviations form the prescribed plan of care; also known as focus charting
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Closed Records
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The records of patients who have been discharged from the hospital or whose treatment has been terminated
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Closed-Record Review
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A review of records after a patient has been discharged from the organization or treatment has been terminated
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Compliance
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1. The process of establishing an organizational culture that promotes the prevention, detection, and resolution of instances of conduct that do not conform to federal, state, or private payer healthcare program requirements. 2. The act of adhering to official requirements
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Computerized Provider Order Entry (CPOE) System
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Systems that allow physicians to enter medication or other orders and receive clinical advice about drug dosages, contraindications, or other clinical decision support
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Concurrent Analysis
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A review of the health record while the patient is still hospitalized or under treatment
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Conditions of Participation
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The administrative and operational guidelines and regulations under which facilities are allowed to take part in the Medicare and Medicaid programs; published by the Centers for Medicare and Medicaid Services, a federal agency under the Department of Health and Human Services
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Consent
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A means for residents to convey to healthcare providers their implied or expressed permission to administer care or treatment or to perform surgery or other medical procedures
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Consultation
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The response by one healthcare professional to another healthcare professional's request to provide recommendations and opinions regarding the care of a particular patient/ resident
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Continuous Record Review
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A review of the health records of patients currently in the hospital or under active treatment; part of the Joint Commission survey process
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Contract Service
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An entity that provides certain agreed upon services for the facility, such as transcription, coding, or copying
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Delinquent Health Record
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An incomplete record not finished or made complete within the time frame determined by the medical staff of the facility
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Demographic Information
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Information used to identify an individual, such as name, address, gender, age, and other information linked to a specific person
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Digital Dictation
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A process in which vocal sounds are converted to bits and stored on computer for random access
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Discharge Analysis
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An analysis of the health record at or following discharge
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Discharge Summary
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A summary of the resident's stay at the long-term care facility that is used along with the post-discharge plan of care to provide continuity of care for the resident upon discharge from the facility
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Disposition
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For outpatients, the healthcare practitioner's description of the patient's status at discharge. For inpatients, a core health data element that identifies the circumstances under which the patient left the hospital
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Do Not Resuscitate (DNR) Order
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An order written by the treating physician stating that in the event the patient suffers cardiac or pulmonary arrest, cardiopulmonary resuscitation should not be attempted
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Electronic Signature
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1. Any representation of a signature in digital form, including an image of a handwritten signature 2. The authentication of a computer entry in a health record made by the individual making the entry
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Emergency Medical Treatment and Active Labor Act (EMTALA)
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To ensure that emergency patients are made aware of their rights, transfer and acceptance policies and procedures must be delineated to ensure that facilities comply with this act
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Enterprise-Wide Master Patient Index (EMPI)
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An index that provides access to multiple repositories of information from overlapping patient populations that are maintained in separate systems and databases
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Family Numbering
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A filing system, sometimes used in clinic settings, in which an entire family is assigned one number
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History
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The pertinent information about a patient, including chief complaint, past and present illnesses, family history, social history, and review of body systems
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Hybrid Record
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A health record that includes both paper and electronic elements
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Incentive Pay
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A system of bonuses and rewards based on employee productivity; often used in transcription areas of healthcare facilities
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Informed Consent
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1. A legal term referring to a patient's right to make his or her own treatment decisions based on the knowledge of the treatment to be administered or the procedure to be performed. 2. An individual's voluntary agreement to participate in research or to undergo a diagnostic, therapeutic, or preventive medical procedure
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Integrated Health Record
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A system of health record organization in which all of the paper forms are arranged in strict chronological order and mixed with forms created by different departments
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Licensure
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The legal authority or formal permission from authorities to carry on certain activities that by law or regulation require such permission (applicable to institutions as well as individuals)
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Longitudinal Health Record
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A permanent, coordinated patient record of significant information listed in chronological order and maintained across time, ideally from birth to death
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Master Patient Index (MPI)
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A list or database created and maintained by a healthcare facility to record the name and identification number of every patient who has ever been admitted or treated in the facility
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Medical Transcription
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The process of deciphering and typing medical dictation
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Medicare
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A federally funded health program established in 1965 to assist with the medical care costs of Americans sixty-five years of age and older as well as other individuals entitled to Social Security benefits owing to their disabilities
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Microfilming
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A photographic process that reduces an original paper document into a small image on film to save storage space
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National Association for Home Care (NAHC)
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The nation's largest trade association representing the interests and concerns of home care agencies, hospices, and home care aide organizations
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National Hospice and Palliative Care Organization (NHPCO)
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Organization whose mission is to lead and mobilize social change for improved care at the end of life
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Notice of Privacy Practices
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A statement (mandated by the HIPAA privacy rule) issued by a healthcare organization that informs individuals of the uses and disclosures of patient-identifiable health information that may be made by the organization, as well as the individual's rights and the organization's legal duties with respect to that information
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Ongoing Records Review
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A review of the health records of patients currently in the hospital or under active treatment; part of the Joint Commission survey process
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Optical Imaging Technology
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The process by which information is scanned onto optical disks
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Outsourcing
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The hiring of an individual or a company external to an organization to perform a function either on site or off site
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Overlap
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Occurs when a patient has more than one medical record number assigned across more than one database
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Overlay
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Occurs when one patient record is overwritten with data from another patient's record
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Personal Digital Assistants (PDA's)
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A hand-held micro-computer, without a hard drive, that is capable of running applications such as e-mail and providing access to data and information, such as notes, phone lists, schedules, and laboratory results, primarily through a pen device
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Point-Of-Care Review
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A review of the health records of patients currently in the hospital or under active treatment; part of the Joint Commission survey process
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Principal Diagnosis
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The disease or condition that was present on admission, was the principal reason for admission, and received treatment or evaluation during the hospital stay or visit
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Problem-Oriented Medical Record (POMR)
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A way of organizing information in a health record in which clinical problems are defined and documented individually; also called problem-oriented health record
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Progress Notes
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The documentation of a patient's care, treatment, and therapeutic response that is entered into the health record by each of the clinical professionals involved in a patient's care, including nurses, physicians, therapists, and social workers
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Qualitative Analysis
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A review of the health record to ensure that standards are met and to determine the adequacy of entries documenting the quality of care
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Quantitative Analysis
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A review of the health record to determine its completeness and accuracy
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Queuing
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Involves a process of making the record available to a particular user
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Retention
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1. The process whereby inactive health records are stored and made available for future use in compliance with state and federal requirements 2. The ability to keep valuable employees from seeking employment elsewhere
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Retention Schedules
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Timetables specifying how long various records are to be maintained according to rules, regulations, standards, and laws
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Scanning
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The process by which a document is read into an optical imaging system
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Serial Numbering System
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A type of health record identification and filing system in which patients are assigned a different but unique numerical identifier for every admission
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Source-Oriented Health Record
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A system of health record organization in which information is arranged according to the patient care department that provided the care
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Straight Numeric Filing System
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Records are filed in numerical order according to the number assigned
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Telestaffing
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A work arrangement (often used by coding and transcription personnel) in which at least a portion of the employee's work hours is spent outside the office (usually in the home) and the work is transmitted back to the employer via electronic means
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Terminal-Digit Filing System
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A system of health record identification and filing in which the last digit or group of digits (terminal digits) in the health record number determines file placement
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Transcription
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The process of deciphering and typing medical dictation
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Unique Identifier
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A type of information that refers to only one individual or organization
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Unit Numbering System
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A health record identification system in which the patient receives a unique medical record number at the time of the first encounter that is used for all subsequent encounters
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Universal Chart Order
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A system in which the health record is maintained in the same format while the patient is in the facility and after discharge
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Voice Recognition Technology
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A method of encoding speech signals that do not require speaker pauses (but uses pauses when they are present) and of interpreting at least some of the signals' content as words or the intent of the speaker
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Serial-Unit Numbering System
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A health record identification system in which patient numbers are assigned in a serial manner but records are brought forward and filed under the last number assigned
