Administrative information: Information used for administrative and healthcare operation purposes, such as billing and quality oversight. Advance directive: A legal, written document that describes the patient’s preferences regarding future healthcare or stipulates the person who is authorized to make medical decisions in the event the patient is incapable of communicating his or her preference.
American Recovery and Reinvestment Act (ARRA):An economic stimulus package enacted by the 111th United States Congress in February 2009; signed into law by President Obama on February 17th, 2009; an unprecedented effort to jumpstart the economy, create/save millions of jobs, and put a down payment on addressing long-neglected challenges. Ancillary services: Tests and procedures ordered by a physician to provide information for use in patient diagnosis or treatment. OR.
Professional healthcare services such as radiology, laboratory, or physical therapy. Attending physician: The physician primarily responsible for the care and treatment of a patient. Autopsy report: Written documentation of the findings from a postmortem pathological examination. Bar Code Medication Administration (BCMA): An electronic system of administering medication that makes use of specific bar code identifiers for each medication. Cardiology report: A report written by a cardiologist interpreting the results of cardiac diagnostic tests.
Care plan: The specific goals in the treatment of an individual patient, amended as the patient’s condition requires, and the assessment of the outcomes of care. Case management: The process of developing a specific are plan for a patient that serves as a communication tool to improve quality of care and reduce cost. Clinical information: Health record documentation that describes the patient’s condition and course of treatment. Clinical pathway: A tool designed to coordinate multidisciplinary care planning for specific diagnoses and treaments.
Clinical practice guideline: A detailed, step-by-step guide used by healthcare practitioners to make knowledge-based decisions related to patient care and issued by an authoritative organization such as a medical society or government agency. Clinical protocol: Specific instructions for performing clinical procedures established by authoritative bodies, such as medical staff committees, and intended to be applied literally and universally.
Commission on Accreditation of Rehabilitation Facilities (CARF): A private, not-for-profit organization that develops customer focused standards for behavioral healthcare and medical rehabilitation programs and accredits such programs on the basis of its standards. Computerized physician order entry (CPOE): Electronic prescribing system that allows physicians to write prescriptions and transmit them electronically. Consent to treatment: Legal permission given by a patient or a patient’s legal representative to a healthcare provider that allows the provider to administer care and/or treatment or to perform surgery and/or other medical procedures.
Consultation report: Health record documentation that describes the findings and recommendations of consulting physicians. Data: The dates, numbers, images, symbols, letters, and words that represent basic facts and observations about people, processes, measurements, and conditions. Demographic data: Information used to identify an individual, such as a name, address, gender, age, and other information lined to a specific person.
Discharge summary: A summary of the resident’s stay at a healthcare facility that is used along with the postdischarge plan of care to provide continuity of care upon discharge from the facility. Do-not-resuscitate (DNR) order: An order written by the treating physician stating that in the even the patient suffers cardiac or pulmonary arrest, cardiopulmonary resuscitation should not be attempted. Dumping: The illegal practice of transferring uninsured and indigent patients who need emergency services from one hospital to another hospital solely to avoid the cost of providing uncompensated services.
Emergency Medical Treatment and Active Labor Act (EMTALA): A 1986 law enacted as part of the Consolidated Omnibus Reconciliation Act largely to combat “patient dumping” – the transferring, discharging, or refusal to treat indigent emergency department patients because of their inability to pay. Encounter note: The record of clinical observations of a patient in the hospital, recorded in chronological order by every physician and clinician who sees or treats the patient in an ambulatory setting.
Expressed consent: The spoken or written permission granted by a patient to a healthcare provider that allows the provider to perform medical or surgical services. Financial data: The data collected for the purpose of managing the assets and expenses of a business Flowchart: A graphic tool that uses standard symbols to visually display detailed information, including time and distance, of the sequential flow of work of an individual or a product as it progresses through a process.
History: Part of a patient’s medical record; a summary of the patient’s illness provided by the patient and documented by the attending physician. Hospitalist: Physicians employed by teaching hospitals to play the role that admitting physicians fulfill in hospitals that are not affiliated with medical training programs/ Imaging report: Radiologists’ written interpretations of imaging procedures such as X-ray examinations, CT scans, MRI and positron-emission tomography.
Implied consent: The type of permission that is inferred when a patient voluntarily submits to treatments Interval note: Health record documentation that describes the patient’s course between two closely related hospitalizations directed toward the treatment of the same complaint when a patient has been discharged and readmitted within 30 days. Intraoperative anesthesia record: Health record documentation that describes the entire surgical process from the time the operation began until the patient left the operating room.
Labor and delivery record: Health record documentation that takes the place of an operative report for patients who give birth in the obstetrics department of an acute care hospital. Laboratory report: The analysis of a laboratory procedure, generated automatically by electronic testing equipment or written by a medical technologist or other specialist. Living will: A directive that allows an individual to describe in writing the type of healthcare that he or she would not like to receive.
Master patient index (MPI): A patient-identifying directory referencing all patients related to an organization and which also serves as a link to the patient record or information, facilitates patient identification, and assists in maintaining a longitudinal patient record from birth to death. Medical staff bylaws: Standards governing the practice of medical staff members. Medication administration record (MAR):The records used to document the date and time each dose and type of medication is administrated to a patient.
Neurology report: Report describing the neurological status of patients. Notice of privacy practices: A statement 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. Nursing assessment: The assessment performed by a nurse to obtain clinical and personal information about a patient shortly after he or she has been admitted to a nursing unit.
Operative report: A formal document that describes the events surrounding a surgical procedure or operation and identifies the principal participants in the surgery. Pathology report: A type of health record or documentation that describes the results of a microscopic and macroscopic evaluation of a specimen removed or expelled during a surgical procedure. Patient assessment instrument (PAI): A standardized tool used to evaluate the patient’s condition after admission to, and at discharge from, the healthcare facility.
Patient’s rights: Rights conferred to Medicare patients by the Medicare Conditions of Participation, such as the right to receive accurate information, the right to choose healthcare providers, and the right to access emergency services. Physician’s order: A physician’s written or verbal instructions to the other caregivers involved in a patient’s care. Postoperative anesthesia record: Health record documentation that contains information on any unusual events or complications that occurred during surgery as well as information on the patient’s condition at the conclusion of surgery and after recovery from anesthesia.
Preoperative anesthesia evaluation: An assessment performed by an anesthesiologist to collect information on a patient’s medical history and current physical and emotional condition that will become the basis of the anesthesia plan for the surgery to be performed. Principal diagnosis: 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 OR the reason established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care.
Principal procedure: The procedure performed for the definitive treatment of a condition ot for care of a complication. Recovery room record: A type of health record documentation used by nurses to document the patient’s reaction to anesthesia and condition after surgery. Standing order: An order the medical staff or an individual physician has established as routine care for a specific diagnosis or procedure. Transfer record: A review of the patient’s acute stay along with current status, discharge and transfer orders, and any additional instructions that accompanies the patient when he or she is transferred to another facility.
Transfusion record: Health record documentation that includes information on the type and amount of blood products a patient received, the source of the blood products, and the patient’s reaction to them. Uniform Ambulatory Care Data Set (UACDS): A data set developed by the National Committee on Vital and Health Statistics consisting of a minimum set of patient or client specific data elements to be collected in ambulatory care settings.
Uniform Hospital Discharge Data Set (UHDDS): A core set of data elements adopted by the US Department of Health, Education, and Welfare in 1974 that are collected by hospitals on all discharges and all discharge abstract systems. Unique identifier: A type of information that refers to only one individual or organization. Visit note: The records of clinical observations of a patient in the hospital, recorded in chronological order by every physician and clinician who sees or treats the patient in an ambulatory setting.