tailieunhanh - Ebook Essentials of health information management - Principles and practices (2E): Part 2

(BQ) Part 2 book “Essentials of health information management - Principles and practices” has contents: Indexes, registers, and health data collection, legal aspects of health information management, introduction to coding and reimbursement, and other contents. | Chapter 6 Content of the Patient Record: Inpatient, Outpatient, and Physician Office Chapter Outline • • • • • • • • • • • • • • Key Terms Objectives Introduction General Documentation Issues Hospital Inpatient Record—Administrative Data Hospital Inpatient Record—Clinical Data OPPS Major and Minor Procedures Hospital Outpatient Record Physician Office Record Forms Control and Design Internet Links Summary Study Checklist Chapter Review Key Terms addressograph machine admission note admission/discharge record admitting diagnosis advance directive advance directive notification form against medical advice (AMA) alias ambulance report ambulatory record ancillary reports ancillary service visit anesthesia record antepartum record anti-dumping legislation APGAR score attestation statement automatic stop order autopsy autopsy report bedside terminal system birth certificate 119 birth history case management note certificate of birth certificate of death chief complaint (CC) clinical data clinical résumé comorbidities complications conditions of admission consent to admission 120 • Chapter 6 consultation consultation report death certificate dietary progress note differential diagnosis discharge note discharge order discharge summary doctors orders DRG creep durable power of attorney emergency record encounter encounter form face sheet facility identification family history fee slip final diagnosis first-listed diagnosis follow-up progress note forms committee graphic sheet health care proxy history history of present illness (HPI) informed consent integrated progress notes interval history labor and delivery record licensed practitioner macroscopic maximizing codes medication administration record (MAR) necropsy necropsy report neonatal record newborn identification newborn physical examination newborn progress notes non-licensed practitioner nurses notes nursing care plan nursing discharge summary nursing documentation obstetrical record occasion of .

• Y khoa - Dược
• Health information management
• Health data collection
• Legal aspects
• Filing systems
• Physician office record
• Loose filing