Acronyms
CPOE
Computerized Physician Order Entry
Chronological record of clinical observation
Progress Notes
Free of errors
Accuracy
The granting of a license
Licensure
CC
Complication / Comorbidity
DRG
Diagnostic Related Group
Drug information and Name of medication
Medication Record
Useful sources for a purpose
Relevancy
The action or process of officially recognizing someone as having a particular status
Accreditation
HIE
Health Information Exchange
CDI
Clinical Documentation Information
Tests performed
Lab Report
All the data is included
Comprehensiveness
A question posed to a documenting physician during the patient's stay
Concurrent query
H & P
History and Physical
DBMS
Data Base Management System
Documentation during surgery and how the patient reacts to anesthesia
Intraoperative Anesthesia Record
Attributes and values to the record are defined
Granularity
A tool used to manage the quality of healthcare concerning the standard care process
Clinical Pathway
PHI
Protected Health Information
HAC
Hospital Acquired Condition
Documents the patients recovery and their reaction to anesthesia
Recovery Room Record
Values are strictly stated
Precision
When a patient directly informs the doctor of their consent, Usually in writing
Expressed Consent
PI
Performance Improvement