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PN 108 FUNDAMENTALS EXAM 1 VOCABULARY
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PN 108 FUNDAMENTALS EXAM 1 VOCABULARY...
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charting - ANSWER documenting important information andobservations about residents
Auditors - ANSWER People appointed to examine patient charts and
health records to assess the quality of care
Electronic Health Record (EHR) - ANSWER An electronic record of
health-related information on an individual that conforms to nationally
recognized interoperability standards and that can be created, managed,
and consulted by authorized clinicians and staff across more than one
healthcare organization
The five basic purposes for accurate and complete patient records -
ANSWER documented communication; (2) permanent record for
accountability; (3) legal record of care; (4) teaching; and (5) research
and data collection
peer review - ANSWER an appraisal by professional coworkers of
equal status
Quality Assurance - ANSWER an audit in health care that evaluates
services provided and the results achieved compared with accepted
standards.
Diagnosis-related groups (DRGs) - ANSWER A system of analyzing
conditions and treatments for similar groups of patients used to establish
Medicare fees for hospital inpatient services; patients are classified by
their principal diagnosis, surgical procedure, age, and other factors.
nonmenclature - ANSWER a classified system of technical or scientific
names and terminology
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