Chapter 2: Communication, Computer Essentials, and Documentation

active listening

a set of skills that enables one to become a more effective listener. The skills include concentrating on the speaker, getting ready to listen by clearing one’s mind of distracting thoughts, using silent pauses when appropriate, providing reassuring feedback, verifying the conversation that took place, keeping personal judgments to oneself, paying attention to the body language of the person speaking, and maintaining eye contact.

bar codes

series of light and dark bands of varying widths that relate to alphanumeric symbols. They can correspond to the patient’s name and/or identification numbers.

beliefs

doctrine or faith of a person or group (i.e., spiritual orientation, family bonds, etc.).

blind

visually impaired or low vision; refers to all people who need alternative techniques to do the same tasks that a sighted person can do normally.

Braille

traditional writing system for sightless individuals; consists of patterns of raised dots read by touch.

central processing unit (CPU)

the main controller of a computer.

clinical (or medical) record

definitive documents (paper or electronic) that contain a chronological log of a patient’s care. It must include any information that is clinically significant or relevant to the patient’s care.

cloud computing

computer network that can be a wide area network (WAN) for numerous groups of users or a local area network (LAN) within an organization

computerized patient record (CPR)

computerized version of a medical/clinical record.

confidentiality

the protected right and duty of health care workers not to disclose any information acquired about a patient to those who are not directly involved with the care of the patient.

critical value

a laboratory result that indicates a pathophysiologic state at such variance with normal as to be life

culture

a system of values (individualism, importance of education and financial security), beliefs (spiritual, family bonding), and practices (food, music, traditions) that stem from one’s concept of reality. Culture influences decisions and behaviors in many aspects of life.

Current Procedural Terminology (CPT)

an alphanumeric coding system used to describe specific medical or laboratory tests, surgeries, evaluations, and other medical procedures performed by a health care worker on a patient. There are thousands of CPT codes, which are used for billing purposes, tracking health data, and measuring performance and efficiency.

date of birth (DOB)

a patient’s age; personal information (i.e., birthday) included in a patient’s medical record and on laboratory test requests.

delta checks

quality control that allows for detection of clinically significant changes in laboratory results.

electronic medical or health record (EMR or EHR)

computerized version of a medical/clinical record. Also referred to as electronic health record (EHR).

e-mail

electronic mail often used in health care facilities. Guidelines for using e-mail, including a patient’s consent to use e-mail, are now required of health care facilities.

hardware

a computer, the programmable machine; the brain of the machine that executes activities.

health literacy

written, spoken, or conceptual knowledge of health information.

International Statistical Classification of Disease and Related Health Problems (IDC)

a coding method that is based on body system or medical conditions or symptoms.

laboratory information system (LIS)

dedicated hardware and software for clinical laboratories and/or anatomical pathology.

lesbian, gay, bisexual, transgender, queer, or questioning (LGBTQ)

individuals who identify as lesbian, gay, bisexual, transgender, queer, or questioning gender identity.

pace (of voice)

the rate of speed and urgency of the voice.

personal digital assistant(PDA)

portable/handheld computer, smartphone, or other device that allows Internet access, usually has touch

radio frequency identification (RFID)

another form of identification tag used in health care for identifying and tracking records, equipment and supplies, specimens, and patients. RFID tags are silicon chips that transmit data to a wireless receiver.

read

back

requisition

paper

security password

a sequence of characters that enable access to part(s) of a computer system.

software

the instructions or computer programming language that operates computer hardware.

specimen collection manual

electronic or paper

STAT

an emergency or critical situation that requires immediate action; in the case of blood collection and analysis, tests that are ordered “STAT” should be given the highest priority for collection, delivery to the laboratory, analysis, and reporting.

storage

relates to the amount of data that can be housed on a computer system’s hard drive or other type of storage device.

tone (of voice)

the pitch of the voice ranging from high to low; also called intonation.

traditions

customs and behaviors associated with groups, such as holidays, foods, music, dance, health care practices, etc.

transgender

a broad term that may include all individuals whose gender identity or expression does not align with their assigned birth sex and/or those whose gender identity is outside of the traditional male or female classification.

universal serial bus (USB)

a connector or computer hardware used to attach a range of devices from a standardized interface device to storage devices and other equipment.

values

the accepted principles of a group (i.e., individualism vs. socialism, importance of education and financial security, competition vs. cooperation, sanctity of life, etc.).

zone of comfort

area of space surrounding a person/patient that is considered “private or personal”; if a stranger (or phlebotomist) gets too close to the individual (i.e., beyond the zone of comfort), the person/patient may begin to feel uncomfortable.