CH 1 WORD SHARE Flashcards
(20 cards)
Health Insurance Portability and Accountability Act sets federal standards to protect records
HIPAA
Records the patient’s care throughout the day
Nurse’s Notes:
Doctor’s daily record of patient’s condition
Physician’s Progress Notes
Given by a specialist when the physician asks for patient evaluation
Consultation Reports:
reports from various treatments and therapies
Ancillary Reports:
Report from surgeon detailing the operation
Operative Report:
Relates details of drugs given to patient
Anesthesiologist’s Report:
Results of all diagnostic tests performed on the patient
Diagnostic Reports:
Report given by pathologist who studies tissue removed from patient
Pathologist’s Report:
Document voluntarily signed by the patient or responsible party
Informed Consent:
Provides services to treat diseases for a short period of time
Acute Care Hospital:
Provides care for specific type of disease
Specialty Care Hospital:
Provides long-term care for patients who need extra time to recover
Nursing Home:
For patients who do not need overnight care
Outpatient Clinic:
Provides wide range of services in a pre-paid system
Health Maintenance Organization:
Outline of patient’s entire hospital stay
Discharge Summary
Agencies that provide services in a patient’s home
Home Health Care:
Provides physical and occupational therapy
Rehabilitation:
provide supportive treatment to terminally ill patients and their families
Hospice
Documents details of hospital stay or doctor’s appointment
Medical Record:
