| A | B |
|---|
| abstracting | collection of data from the medical record for collection and planning purposes |
| analysis | reviewing the medical record to determine that all required documentation |
| cancer registry | a database of patients diagnosed with cancer |
| coding | assignment of numbers to diagnoses and/or procedures using the current edition of a coding or classification system such as the ICD or CPT |
| deficiency slip | document that identifies deficiencies in documentation |
| Health Information Management Department | responsible for maintaining security and confidentiality of patient's records and for promoting their responsible use |
| JCAHO | Joint Commission on the Accredidation on the Accredidation of Health Care Organizations lthcare Organizations |
| medical record | multiform document detailing the patient's diagnosis, diagnostic testing , and treatment given during an encounter with a hospital |
| medical record number | a unique number assigned to a medical record in order to identify it |
| medical transcription | interpretation and typing of reports dictated by physicians and other healthcare personnel |
| Medicare | Federal insurance for patients over 65 or for the disabled |
| performance improvement | evaluating the overall performance of a health care facility |
| periodical | a magazine or journal published at specific periods, for example, weekly or monthly |
| physician incomplete area | area of the HIM dept. where physicians come to work on incomplete records |
| physician progress note | handwritten or typed entries made by the physician regarding the patient's progress during hospitalization or other treatment |
| risk management | addressing the risk to which patients, visitors, hospital staff, medical staff, vendors, and others are exposed |
| 6 functions of a medical record | document of patient care; legal document;statistics; substantiating billing charges;teaching;performance improvement |
| 4 functions of HIM dept | storage and retrieval;release of information;coding;abstracting |
| 3 different types of dictation systems | endless loop recording;cassette;digital |
