Acronyms
CPR
What is computer-based patient record
Time limit for hospital-based outpatient observation
What is less than 24 hours
Free text
What is unstructured data
Receive treatment of minor injuries or preventative care
What is primary care
Accreditation organisation that also regulates health record content
What is the Joint Commission
PCMH
What is Patient-centered medical Home
Time limit for a physician to complete an inpatient H&P after admission
What is 48 hours
X-rays, CT Scans
What are Diagnostic Imaging Data
Treatment for injury or illness that could be disabling or life threatening
What is Emergency and trauma care
Summary of the patients illness documented by the attending
What is Medical History
PHR
what is personal health record
The number of days for a physician to respond to a query
What is 5
Collected during registration and may include full name, address, date of birth, contact information, admission date.
What is demographic data
Professional nursing and medical care after the acute phase of an injury or illness
What is skilled nursing care or subacute care
Instructions for care and treatment from the doctor
What is physician orders
ONC
What is office of the Office of the National Coordinator for Health Information Technology
The number of days allowed to complete a discharge summary for most patients
What is 30
where to locate insurance company, policy number, employer of the patient
What is Financial Data
Diagnosis and therapeutic services from a specialist
What is secondary care
Record of vitals including pain level
What is nursing notes
NCHS
What is the National Center for Health Statistics
Number of days required to complete a preoperative history and physical
What is no more than 7 days
Acknowledgements and consents
What is preliminary clinical data
Highly specialized care like organ transplantation or intensive care
What is tertiary care
Daily record of patient assessment by the doctor
What is the physicians' progress notes