Across
- 4. (2 words) This can be a formally prepared sheet or often it is just noted on the progress note.
- 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.
- 7. (2 words) Any information pertaining to someone's physical or mental health, condition or infirmity.
- 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.
- 11. This is simply the paper chart
- 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
- 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. (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. (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. (2 words) Any time you are in an OR a report will be generated and sent to the family physician
- 5. (2 words) This documentation MUST occur each and every time a patient comes into the office.
- 8. This is simply the electronic chart
- 10. (2 words) This are the results from various labs or diagnostic imaging tests that have been done to a patient.
- 12. (2 words) This is a questionnaire that the patient fills out usually on their first visit to the providers office.