Test 3 Review Chapter 13 Health Information Management

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Across
  1. 4. (2 words) This can be a formally prepared sheet or often it is just noted on the progress note.
  2. 6. (3 words) This should be listed in a prominent place. There is often a giant red sticker on the front of the chart so the healthcare providers know to look closely at the chart.
  3. 7. (2 words) Any information pertaining to someone's physical or mental health, condition or infirmity.
  4. 9. (2 words) Any documentation relating to a health-care client. The term could be used for a single document or a collection of docutments.
  5. 11. This is simply the paper chart
  6. 13. (3 words) An accumulation of essential information from an individual's electronic medical record that is accessed electronically at different points of service for the purpose of quality patient care, even across the country
  7. 14. (3 words) This is the legal health record in digital format. It contains the patient's health information collected by one or a group of providers in one location.
Down
  1. 1. (2 words) Any information that may be considered factual or subjective. It can include any personal descriptors, identification numbers, ethnicity, health information, or financial information
  2. 2. (3 words) This starts with the answers to the history questionnaire and is updated periodically to provide a cumulative view of the patient's history and current health status
  3. 3. (2 words) Any time you are in an OR a report will be generated and sent to the family physician
  4. 5. (2 words) This documentation MUST occur each and every time a patient comes into the office.
  5. 8. This is simply the electronic chart
  6. 10. (2 words) This are the results from various labs or diagnostic imaging tests that have been done to a patient.
  7. 12. (2 words) This is a questionnaire that the patient fills out usually on their first visit to the providers office.