Question

Chapter 19 The Record 34T Group B The ability to work with other with other systems plan for retaining or keeping vement from active to inactivdosed Word Pool 12. A method or pl and for their moveme alth records 11. Occurring later or after controls how something should b 14. A rule that control boundaries u idelines or patient portal Vested interoperability e-prescribing compliance computerized physician provider oder entry ICPOE parameters interface retention schedule An interconnection between system A secure online website that gives onal health information using a ebsite that gives patients 2 heraccess to Information using a username usword conic software to communicate with pharmacies 17. The use of electronics tering medication orders or other provider standards and regulations of the practice's and send prescribing information The process of entering medication instructions into the EHR 19. Meeting the standards an established policies and procedures 20. Granted or endowed with to have a special interest in endowed with a particular authority, right or property: Group C 21 The age at which a person is recognized by law to be an adult; varies by state 72. A heading, title, or subtitle under which records are filed Word Pool age of majority reverse chronological order obliteration transcription dictation out guides caption alphabetic filing numeric filing tickler file 23. To say something aloud for another person to write down 24. A chronologic file used as a reminder that something must be dealt with on a certain date 25. The filing of records, correspondence, or cards by number 26. To make a written copy of dictated material 27. A sturdy cardboard or plastic file-sized card used to replace a folder temporarily removed from the filing space 28. To remove or destroy all traces of; do away with; destroy completely 29. The most recent item is on top and oldest item is last Any system that arranges names or topics according Sequence of the letters in the alphabet

Answer 1

GROUP B

11.Interoperability

12.retention schedule

13.subsequent

14.compliance

15.interface

16.patient portal

17.e- prescribing

18.computerized physician/provider order entry(CPOE)

19.parameters

20.vested

GROUP C

21.age of majority

22.caption

23.dectation

24.tickler file

25.numeric filing

26.transcription

27.out guides

28.obliteration

29.reverse chronological order

30.alphabetic filing

A.Health record basics

a.demographics: demographic data is the information about the patient collected at the time of registration or first interview.it includes,age,gender,race,and ethnicity,profession and occupation,marital status etc.

b.past health history is the total health status of the patient just prior to the presenting problem.

c.family history is the record of health related information about the patient and his or her close relatives,eg.parents,siblings.

d.social history:expresses the familial,occupational and recreational aspects of the patient's personal life.

e.cheif complaint: is the primary problem of the patient that insisted the patient to take medical assistance and attention.

f.vital signs and anthropometric measurements:are the basic health measurements of the patient.which includes,blood pressure,temperature,respiratory rate,pulse rate,height and weight,

g.Diagnosis:diagnosis means the identification of the disease or illness by examining the patient's problems or symptoms.

h.progress notes: these are the parts of a patient's health record where health care team/professionals document patients clinical status through out the hospitalization or the period of out patient care.