Introduction to health care management
Study online at https://quizlet.com/_3e5e2j
1. Health record Paper/computer based tool for collecting/storing informationabout the health-
care services provided to a patient in a single facility.
2. Primary uses of Deliver and manage patient care, communication tool for entire healthcare team,
medical records support for data analysis of trends financial and administrative purposes, patient
(4) self management maintaining (PHR).
3. Secondary use of Assist in research, education, regulation, public health, homeland security and
medical record policy making.
4. Primary user Healthcare team
of the medical
record
5. Aggregate data Data extracted from patient record and its de-identified information making it
possible to compare and analyze data about many patients
6. Healthcare Process by which the medical record containing details of patients visits is created
documentation and stored.
process
7. What are the Pt. Visits physician, physician documents care provided, coder codes encounter
(9) steps in using documentation, coded information is abstracted into the system or entered
the documenta- onto bill, encounter is billed to third party payer and completed documents are
tion process filed
8. EHR Electronic health record.
9. CAC Computer assisted coding software. Automatically assigns codes based on the
documentation provided in the EHR. Coder in this case becomes the editor
10. Medical record Collect patient data and store it so as to be accessible to all needing access.
(main function)
, Introduction to health care management
Study online at https://quizlet.com/_3e5e2j
11. Patient informa- Facts about the patient(patient demographics) either verbal/written. Patient sup-
tion plied information form the foundation of the medical record.
12. Healthcare work- Provide the medical detail to the record initiated by registration or clinical staff.
er
13. Patient demo- Includes name address, telephone number, gender, dob,ins/billing info
graphics
14. Methods used to Subjective and objective
obtain patient in-
formation
15. Subjective Dependent on the mind or on an individuals perception for its existence. A
symptom or condition perceived by the patient and not the examiner
16. Objective Not influenced by personal feelings, interpretations, or prejudice; based on fact;
unbiased; an objective opinion.
17. Descriptive infor- Story or account of the events, experiences
mation
18. Assessment Assessing, evaluation; rendering an opinion. Summary of findings place in record
where physician documents his or her conclusions regarding the patients condi-
tion.
19. Plan Series of steps to be carried out or goals to be accomplished; a scheme, pro-
gram,or method worked out beforehand for the accomplishment of an objective.
20. UHDDS Uniform hospital discharge data set
21. UHDDS - defini- Set of definitions collected on all hospital inpatients: principal diagnosis, principal
tion procedure, discharge date and discharge status
Study online at https://quizlet.com/_3e5e2j
1. Health record Paper/computer based tool for collecting/storing informationabout the health-
care services provided to a patient in a single facility.
2. Primary uses of Deliver and manage patient care, communication tool for entire healthcare team,
medical records support for data analysis of trends financial and administrative purposes, patient
(4) self management maintaining (PHR).
3. Secondary use of Assist in research, education, regulation, public health, homeland security and
medical record policy making.
4. Primary user Healthcare team
of the medical
record
5. Aggregate data Data extracted from patient record and its de-identified information making it
possible to compare and analyze data about many patients
6. Healthcare Process by which the medical record containing details of patients visits is created
documentation and stored.
process
7. What are the Pt. Visits physician, physician documents care provided, coder codes encounter
(9) steps in using documentation, coded information is abstracted into the system or entered
the documenta- onto bill, encounter is billed to third party payer and completed documents are
tion process filed
8. EHR Electronic health record.
9. CAC Computer assisted coding software. Automatically assigns codes based on the
documentation provided in the EHR. Coder in this case becomes the editor
10. Medical record Collect patient data and store it so as to be accessible to all needing access.
(main function)
, Introduction to health care management
Study online at https://quizlet.com/_3e5e2j
11. Patient informa- Facts about the patient(patient demographics) either verbal/written. Patient sup-
tion plied information form the foundation of the medical record.
12. Healthcare work- Provide the medical detail to the record initiated by registration or clinical staff.
er
13. Patient demo- Includes name address, telephone number, gender, dob,ins/billing info
graphics
14. Methods used to Subjective and objective
obtain patient in-
formation
15. Subjective Dependent on the mind or on an individuals perception for its existence. A
symptom or condition perceived by the patient and not the examiner
16. Objective Not influenced by personal feelings, interpretations, or prejudice; based on fact;
unbiased; an objective opinion.
17. Descriptive infor- Story or account of the events, experiences
mation
18. Assessment Assessing, evaluation; rendering an opinion. Summary of findings place in record
where physician documents his or her conclusions regarding the patients condi-
tion.
19. Plan Series of steps to be carried out or goals to be accomplished; a scheme, pro-
gram,or method worked out beforehand for the accomplishment of an objective.
20. UHDDS Uniform hospital discharge data set
21. UHDDS - defini- Set of definitions collected on all hospital inpatients: principal diagnosis, principal
tion procedure, discharge date and discharge status
