CHAPTER 3 TERMINOLOGY Flashcards
Auditors
people appointed to examine patient charts and health records to assess quality of care.
Chart (health care record)
legal record that is used to meet the many demands of the health, accreditation, medical insurance, and legal systems.
diagnosis- related groups
A system that classifies patients by age, diagnosis, surgical procedure, and other information with hundreds of different catagoriesto predict the use of hospital resources, including length of stay, resulting in a fixed payment amount.
electronic health record
all documentation in the past were hand written, now we use EHR and EMR.
computer on wheels
POC systems; and others use handheld systems.
peer review
an appraisal by professional co workers of equal status.
quality ssurance, assessment, and improvement
is an audit in health care that evaluates services provided and the results achieved compared with accepted standards.
informatics
study of information processing.
narrative charting
reporting of patient care in descriptive form.
nomenclature
a classified system of technical or scientific names and terminology
nursing notes
the form on a patients chart on which nurses record theirobservations, the care given, and the patients responses.
personal health record
extension of the EHR that allows patients to input their own information into an electronic database.
point- of- care
bedside system for inputing information.
problem- oriented medical record
database, problem list, care plan, and progress notes.
Traditional ( block) chart
emphasis is placed on specific sections of information.
