Chapter 3: Health Information Functions, Purpose, and Users

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Across
  1. 3. A review of the health record to determine its completeness and accuracy
  2. 6. Raw facts and figures
  3. 7. A computer software program that automatically assigns prospective payment groups on the basis of clinical codes
  4. 10. A clarification made to the health care documentation after the original document has been signed; it should be dated, timed and signed
  5. 11. Review of health record for proper documentation and adherence to regulatory and accreditation standards
  6. 13. The process of ensuring that each page in the health record is organized in a standardized order
  7. 14. A device used in paper-based health record systems to track the location of records removed from the file storage area
  8. 15. Specialty software used to facilitate the assignment of diagnostic and procedural codes according to the rules of the coding system
  9. 16. Situation in which a patient is issued more than one medical record number from an organization with multiple facilities
  10. 17. The process of extracting information from a document to create a brief summary of a patient’s illness, treatment, and outcome
  11. 19. Request for the health record
  12. 20. Situation in which a patient is issued a medical record number that has been previously issued to a different patient
Down
  1. 1. Edit made to the health record by drawing a single line through the erroneous information and writing the word “error” above the mistake; the practitioner should sign, date and time the correction
  2. 2. An organized (usually alphabetical) list of specific data that serves to guide, indicate, or otherwise facilitate reference to the data
  3. 3. A review of the health record to ensure that standards are met and to determine the adequacy of entries documenting the quality of care
  4. 4. Fixed rules that must be followed
  5. 5. In forms control, provides general direction about the design of the form
  6. 8. A late entry added to a health record to provide additional information in conjunction with a previous entry
  7. 9. Information used to identify an individual, such as name, address, gender, age, and other information linked to a specific person
  8. 12. Refers to data elements that have been combined and then manipulated into something meaningful regarding a patient or a group of patients
  9. 18. A collection of care information related to a specific disease, condition, or procedure that makes health record information available for analysis and comparison