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