Documentation in Health Records

Flashcards covering key vocabulary, documentation methods, and legal considerations in health records.

Electronic Health Records (EHRs)

Digital systems used to document and manage patient health information and medical records across healthcare settings.

Source-Oriented Medical Records

A documentation method where patient data is organized according to the specific source or department providing the information.

Problem-Oriented Medical Records

A documentation method organized around a patient's specific healthcare problems or diagnoses.

SOAP

A documentation method representing Subjective, Objective, Assessment, and Plan.

PIE Model

A documentation model representing Problem, Intervention, and Evaluation.

Focus Charting

A documentation method centered on specific patient concerns, events, or needs.

Charting by Exception

A documentation method where only abnormal findings or deviations from established standards of care are recorded.

Documentation During EHR Downtime

The practice of using alternative paper-based or secondary documentation procedures when the electronic health record system is offline.

HIPAA Privacy Rule

The legal framework under the Health Insurance Portability and Accountability Act that protects the privacy and security of patient health information.

Computerized Provider Order Entry (CPOE)

An electronic system that enables healthcare providers to directly enter medication, laboratory, and clinical orders electronically.