documentation
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refers to both the act of preparing and the evidence created when a
healthcare professional records information regarding a patient during the
course of assessment and treatment; can be handwritten or electronically.
Sign-in sheets
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, help identify new patients who might need to complete forms and help
track arrival times and waiting times.
** Should not request any personal information, because it can be
reviewed by others.
Subjective
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1) when referring to charting, information is supplied by the patient and
includes routine information about the patient, past personal medical
history, family history, and chief complaint
2) relating to the person who is thinking, saying, or doing something;
personal; of a disease symptom, felt by the individual but not perceptible
to others
audit trail
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a record of transaction that identifies by what person or persons and what
time and day an electronic record was accessed in order to maintain
accountability for the security of the information as it is accessed.
Best practice
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, develop a standard w/in the practice of how much time is allotted for each
type of visit.
Indemnity Plans
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These plans offer access to any licensed physician or hospital and are
generally more expensive.
24 hr. notice
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Many appt. cards for professional services state that the pt. must give the
office a ? ? ? if a change in the schedule appt. must be made in order to
avoid a charge.
BP check
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requires only 10 min. intervals
Single Booking scheduling
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Def.: Used when an appointment for a patient will take a longer period of
time. ? ? means a single patient is booked for a specific amount of time.
Pros: Enables the provider to focus on one patient and thoroughly assess
complaints.
Cons: When patients' problems are straightforward and easily addressed,
this method might leave gaps in the schedule that could otherwise be used
more efficiently to see other patients or perform needed ancillary tasks
FU
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follow-up examination
Large C , C&C
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In paper scheduling system, one common practice is to use a large c at the
beginning of the person's name to indicate a cancellation, or ??? to
indicate that the pt. did call to tell you why the appointment had to be
canceled.
Health Information management systems society (HIMSS)
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refers to both the act of preparing and the evidence created when a
healthcare professional records information regarding a patient during the
course of assessment and treatment; can be handwritten or electronically.
Sign-in sheets
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, help identify new patients who might need to complete forms and help
track arrival times and waiting times.
** Should not request any personal information, because it can be
reviewed by others.
Subjective
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1) when referring to charting, information is supplied by the patient and
includes routine information about the patient, past personal medical
history, family history, and chief complaint
2) relating to the person who is thinking, saying, or doing something;
personal; of a disease symptom, felt by the individual but not perceptible
to others
audit trail
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a record of transaction that identifies by what person or persons and what
time and day an electronic record was accessed in order to maintain
accountability for the security of the information as it is accessed.
Best practice
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, develop a standard w/in the practice of how much time is allotted for each
type of visit.
Indemnity Plans
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These plans offer access to any licensed physician or hospital and are
generally more expensive.
24 hr. notice
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Many appt. cards for professional services state that the pt. must give the
office a ? ? ? if a change in the schedule appt. must be made in order to
avoid a charge.
BP check
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requires only 10 min. intervals
Single Booking scheduling
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Def.: Used when an appointment for a patient will take a longer period of
time. ? ? means a single patient is booked for a specific amount of time.
Pros: Enables the provider to focus on one patient and thoroughly assess
complaints.
Cons: When patients' problems are straightforward and easily addressed,
this method might leave gaps in the schedule that could otherwise be used
more efficiently to see other patients or perform needed ancillary tasks
FU
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follow-up examination
Large C , C&C
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In paper scheduling system, one common practice is to use a large c at the
beginning of the person's name to indicate a cancellation, or ??? to
indicate that the pt. did call to tell you why the appointment had to be
canceled.
Health Information management systems society (HIMSS)
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