Across
- 3. term used in many EHR programs for a correction made to an electronic health record
- 4. transforming spoken notes into accurate written form
- 6. sometimes called conventional method, patient information is arranged within a chart or medical record according to who supplied the data.
- 11. electronic record of health-related information for a individual patient that is created, compiled, and managed by providers and staff members located within a single healthcare organizationi
- 12. paitent electronic health information created in a format meeting interoperability standards
- 16. pertaining to data that are readily apparent and measurable, such as vital signs, test results, or physical examination findings
- 18. serves a the "base" for the patient medical record
- 21. to examine and review a group of patient records for completeness and accuracy
- 22. health record that provides a summary of medical information, maintained in electronic or other format by an individual
- 24. primary reason most providers give for not implementing electronic record in their offices.
Down
- 1. inventory of the body obtained by healthcare provider through a series of questions
- 2. known as health insurance portability and accountability act
- 5. filing system that uses the patient problem list as the source for filing within the patient medical record
- 6. are objective, or external factors like blood pressure, rash , swelling
- 7. not following the medical advice a patient receives
- 8. 8th leading cause of patient death in the united states
- 9. maintains users ability to work in certain areas of a patient's EHR
- 10. means getting to the point
- 13. process of recording information in the medical record
- 14. primary problem
- 15. subjective, internal conditions felt by patient-headache or pain
- 17. statistical data relating to the population and particular groups within it
- 19. a reminder file for keeping track of time sensitive obligations
- 20. format of medical records documentation that takes the SOAP format further, breaking it down into smaller components
- 23. subjective, objective, assessment, and plan