Across
- 2. health record that patient keeps but is not admissible in court
- 3. multiple users may use electronic ___ to make patient's appointments
- 5. primary reason most providers give for not implementing electronic records in their offices
- 8. __of action including treatment options, medications, etc.
- 9. when a new patient makes an appointment with the office, certain basic __ information is required.
- 11. data from the physician, exam or test results
- 12. process of recording info in med record
- 13. physician must be able to trust the ___of the information in the medical records
- 14. protection and security act that protects the confidentiality of patient records, etc.
- 15. one of the 6 C's that means "brief and to the point"
- 16. patients primary problem
- 21. records created, compiled and managed by providers//staff located within a single healthcare organization
- 23. one of the 6 C's using precise descriptions and accepted medical terminology describing patient's condition.
Down
- 1. transforming spoken notes into accurate written form
- 4. data from the patient or what the patient describes
- 6. staff requirement disadvantage for EHR programs
- 7. patient information arranged within chart or medical record according to who supplied data
- 10. form that contains the patient's past medical history
- 15. format of medical records documentation broken down into smaller components
- 16. __form signed by patient before procedure is performed
- 17. records utilized by members of more than one healthcare organization
- 18. patient information arranged within chart of medical record including problem list, diagnostic & treatment plan
- 19. diagnosis or impression of patient's problem
- 20. files that can alert and remind staff members about patients
- 22. format using an orderly series of steps for dealing with any medical case.