Basic Healthcare Practices & Medical Scribe Learning Resource

This set of flashcards covers key vocabulary terms and definitions related to communication practices in healthcare, medical documentation, and roles of healthcare providers.

Communication

The process of sharing information, thoughts, and feelings between individuals.

Sender

The person who initiates the communication process by conveying a message.

Receiver

The individual who interprets and reacts to the message sent by the sender.

Feedback

The response from the receiver back to the sender, indicating whether the message was understood.

Nonverbal Communication

Communication that occurs without words, such as gestures, body language, and facial expressions.

Congruency

The agreement between verbal and nonverbal messages; both should align to ensure clear communication.

Active Listening

Fully concentrating, understanding, responding, and remembering what is being said during a conversation.

Open-Ended Questions

Questions that cannot be answered with a simple 'yes' or 'no;' they require elaboration.

Territoriality

The tendency to claim a specific area or space, affecting interpersonal interactions.

Medical Asepsis

Practices aimed at reducing the number of microorganisms and preventing disease transmission.

HIPAA

Health Insurance Portability and Accountability Act; a law that provides privacy and security provisions for patient information.

Charting

Documentation of patient data, including diagnosis, treatment, and progress, within a medical record.

Electronic Health Record (EHR)

A digital version of a patient’s paper chart that is real-time, patient-centered records.

Patient History

Information gained by healthcare providers through questions to help treat patients effectively.

Clinical Documentation

The process of accurately capturing and recording patient healthcare information.

Scribe

A person who documents medical visits and interactions on behalf of healthcare providers.

Malpractice Litigation

Legal actions taken against healthcare professionals for failure to deliver care that meets accepted standards.

Empathy

The ability to understand and share the feelings of another person.