Health Information Management, chapter 4

addendum
(n.) an addition or supplement designed to increase correctness, completeness, or currency
administrative data
information such as the PT full name and address, tel #, and social security # is collected by the office and entered into the registration system as
age of consent
age of majority, which means facilites must retain records for time period (e.g., 18 years) in addition to the retention law.
age of majority
age at which an individual is considered to have all of the legal rights and responsibilities of an adult (most states is age 18)
alternate care facilities
Alternate Cares Facilities that provide behavorial health, home health, hospice, outpatient, skilled nursing, home health, and other forms of care also serve as a documentation source for patient care information
alternate storage facilities
amending the patient record
correcting documentation in the patient record. The only person authorized to correct an entry is th eauthor of the orginal entry.
archived records
records placed in storage and rarely accessed and stored for the long term
assessment (A)
Which initial in SOAP or SOAR covers the inpression, interpretation or judgment based on the analysis of factual data and reference materials?
-, judgement, opinion, or evaluational made by health care provider (e.g. acute migraine)
ASTME 1762-Standard Guide for Authentication of Healthcare Information
audit trail
a report that traces who has accessed electronic information, when information was accessed, and whether any information was changed
auto-authentication
Process by which the failure of an author to review and affirmatively either approve or disapprove an entry within a specific time results in authentication.
chart deficiencies
Missing reports, documentation, and signatures as determined upon patient record analysis
chronological date order
Oldest information is filed first in a section of a discharged patient record
clinical data
Data captured during the process of diagnosis and treatment
countersignature
A form of authentication by an individual in addition to the signature of the original author is called a _________________________.
database
A collection of organized data that allows access, retrieval, and use of data
deficiency slip
done when deficiencies are identified. indicates what reports are missing or require authentication and enters info into computer system that logs/tracks health record deficiencies. multipart with one copy to record and one or more filed by physician name.
delinquent record
An incomplete record not finished or made complete within the time frame determined by the medical staff of the facility
delinquent record rate
To determine the ____________________, divide the total number of delinquent records by the number of discharges in the period.
demographic data
characteristics of subjects or study populations, which include such information as age, sex, family history of the disease or condition for which they are being treated, and other characteristics relevant to the study in which they are participating
diagnostic/management plans
plans to learn more about the patient’s condidtion and the management of the condition
digital archive
A storage solution that consolidates electronic records on a computer server for management or retrieval.
digital signature
A digital code attached to an electronic message or document, which is unique and which can be used to authenticate the sender or owner. Most often used in electronic commerce.
electronic signature
An individualized computer access and identification system(e.g. a series of numbers, letters, electronic writing, voice, computer key, and fingerprint transmission {biometric system}) accepted by both parties to show intent, approval of, or responsibility for computer document content.