Clinical Information and Nonclinical Data

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Administrative information: Information used for administrative and healthcare operation purposes, such as billing and quality oversight. Advance directive: A legal, written document that describes the patient's preferences regarding future healthcare or stipulates the person who is authorized to make medical decisions in the event the patient is incapable of communicating his or her preference. American Recovery and Reinvestment Act (ARRA):An economic stimulus package enacted by the 111th United States Congress in February 2009; signed into law by President Obama on February 17th, 2009; an unprecedented effort to jumpstart the economy, create/save millions of jobs, and put a down payment on addressing long-neglected challenges. Ancillary services: Tests and procedures ordered by a physician to provide information for use in patient diagnosis or treatment. OR. Professional healthcare services such as radiology, laboratory, or physical therapy. Attending physician: The physician primarily responsible for the care and treatment of a patient. Autopsy report: Written documentation of the findings from a postmortem pathological examination. Bar Code Medication Administration (BCMA): An electronic system of administering medication that makes use of specific bar code identifiers for each medication. Cardiology report: A report written by a cardiologist interpreting the results of cardiac diagnostic tests. Care plan: The specific goals in the treatment of an individual patient, amended as the patient's condition requires, and the assessment of the outcomes of care. Case management: The process of developing a specific are plan for a patient that serves as a communication tool to improve quality of care and reduce cost. Clinical information: Health record documentation that describes the patient's condition and course of treatment. Clinical pathway: A tool designed to coordinate multidisciplinary care planning for specific diagnoses and treaments. Clinical practice guideline: A detailed, step-by-step guide used by healthcare practitioners to make knowledge-based decisions related to patient care and issued by an authoritative organization such as a medical society or government agency. Clinical protocol: Specific instructions for performing clinical procedures established by authoritative bodies, such as medical staff committees, and intended to be applied literally and universally. Commission on Accreditation of Rehabilitation Facilities (CARF): A private, not-for-profit organization that develops customer focused standards for behavioral healthcare and medical rehabilitation programs and accredits such programs on the basis of its standards. Computerized physician order entry (CPOE): Electronic prescribing system that allows physicians to write prescriptions and transmit them electronically. Consent to treatment: Legal permission given by a patient or a patient's legal representative to a healthcare provider that allows the provider to administer care and/or treatment or to perform surgery and/or other medical procedures. Consultation report: Health record documentation that describes the findings and recommendations of consulting physicians. Data: The dates, numbers, images, symbols, letters, and words that represent basic facts and observations about people, processes, measurements, and conditions. Demographic data: Information used to identify an individual, such as a name, address, gender, age, and other information lined to a specific person. Discharge summary: A summary of the resident's stay at a healthcare facility that is used along with the postdischarge plan of care to provide continuity of care upon discharge from the facility. Do-not-resuscitate (DNR) order: An order written by the treating physician stating that in the even the patient suffers cardiac or pulmonary arrest, cardiopulmonary resuscitation should not be attempted. Dumping: The illegal practice of transferring uninsured and indigent patients who need...
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