Health Record

medical history

Collection of info about events that might be related to a person's illness. Includes chief complaint, history of present illness, past medical problems, family medical problems, social history, and review of symptoms.

conditions for coverage

Standards applied to facilities that choose to participate in federal government reimbursement programs such as Medicare and Medicaid

physicians orders

a physicians written verbal instructions to the other caregivers involved in the patients care

certification

a record of being qualified to perform certain acts after passing an examination given by an accredited professional organization.

transfer record

a review of the pt's acute stay along with current status, discharge and transfer orders, and any additional instructions that accompanies the pt when he or she is transferred to another facility; also called a referral form

recovery room report

a type of health record documentation used by nurses to document the pt's reaction to anesthesia and condition after surgery, also called recovery room record

anesthesia report

"The report that notes any preoperative medication and response to it, the anesthesia administered with dose and method of administration, the duration of administration, the patient's vital signs while under anesthesia, and any additional products given the patient during a procedure"

operative report

A formal document that describes the events surrounding a surgical procedure or operation and identifies the principal participants in the surgery

patient history questionnaire

A series of structured questions to be answered by patients to provide information to clinicians about their current health status

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

imaging technology

Computer software designed to combine health record text files with diagnostic imaging files

joint commission

Formerly the Joint Commision on Accreditation of Healthcare Organizations. a commission established to improve the quality of care and services provided in organized healthcare setting, through a voluntary accreditation process

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

discharge summary

Part of a patient's medical record. It is a comprehensive outline of the patient's entire hospital stay. It includes condition at time of admission, admitting diagnosis, test results, treatments and patient's response, final diagnosis, and follow-up plans.

expressed consent

Verbal, nonverbal, or written communication by a patient that he wishes to receive medical care.

problem list

a list of all illnesses, injuries, and other factors that affect the health of the pt, usually identifying the time of occurance of identification and resolution

autopsy report

Written documentation of the findings from a postmortem pathological examination

electronic health record (EHR)

a computerized lifelong health care record for an individual that incorporates data from providers who treat the individual

licensure

a government agency authorizes an individual to work in a given occupation after the individual has completed an approved education program and passed a state board test

care plan

a written plan that provides direction for each patient's care, including the goals for the patient and what actions are required to meet them. The plan ensures that nursing care is consistent with the patient's needs and progress toward self-care

computer based patient record (CPR)

electronic patient record housed in a system designed to provide users with access to complete and accurate data, practitioner alerts and reminders, clinical decision making support systems and links to medical knowledge, AKA electronic health record, computerized patient record.

palliative care

provides pain relief and comfort measures but does not try to prolong the person's life

progress notes

the documentation of a pt's care, treatment, and therapeutic response that is entered into the health record by each of the clinical professionals involved in a pt's care, including nurses, physicians, therapists, and social work

patients bill of rights

the protection afforded to individuals who are undergoing medical procedures in hospitals or other healthcare facilities

implied consent

type of consent in which a patient who is unable to give consent is given treatment under the legal assumption that he or she would want treatment