Health Care Information System Terms

Diagnosis

Is a word physicians use to find out the disease a patient is suffering from or the condition of need of the person. This is used when a patient is admitted to the clinic or hospital and people are concerned about the cause of the illness. The physician would reply that he/she would perform a diagnosis to establish the problem. In the case of reporting the cause of illness, the physician may report that the result of the diagnosis done shows the patient is suffering from a given disorder.

Disease registry

A data collection centralized in a specific place for purposes of improving health care delivery services or increasing effectiveness of the care given to customers. The registry is a reference point where the health care practitioners would always refer to in the process of delivering their services. The term can be used when addressing a group of physicians, advising them to make use of the registry in order to find better ways of caring for patients or performing their duties.

Documentation

Is the process of recording and keeping track of healthcare information. The information ranges from new findings, procedures, processes, and reactions to certain treatments. When addressing health practitioners, they can be advised to document all their experiences during the service delivery processes. Importance of documentation can also be addressed and all physicians encouraged keeping good records of what they document.

Disease management

A set program aiming at controlling and eradicate prevalence of a given chronic disease. The program also aims at improving health standards and lifestyles of the patient. In this scenario, Disease management can be used when advising physicians to observe and create programs that can help control an outbreak of a given disease.

Another meaning of Disease management is when patients experiencing heavy attack from a given infection are offered special care to prevent the bacteria from causing more harm to them or infecting others. It can be used when patients are in serious conditions and a special treatment or care is accorded to them as compared to other easy scenarios.

Diagnostic codes

These are letters of the alphabets and numerals that are used to record health issues. Different codes mean different conditions and levels of illness or suffering. When addressing health practitioners, they should be advised to make proper use of diagnostic codes to ensure that correct data and information is given about the condition of a patient. They can also be encouraged to master all the codes as in order to give clear reports.

Delinquent record

This is a record left before completion within a specified period of time. It is incomplete in that it does not reflect the whole procedure that was being applied in attending to a given situation. Incomplete records should be discouraged and all practitioners advised to give full records and data of every healthcare process.

Abstracting

Is the process of creating a summary of a patient’s suffering, treatment and results. The abstract gives most important information and covers almost all the processes of caring for the patient. It is summarized. This term can be used in giving and writing reports to relatives. It can also be used when urgent information is needed by a given person and that the health records manager can simply give an abstract of certain writings or reports by physicians.

Acute care

Is a short term treatment or care given to a patient who did not experience such a fatal injury. the acute care involves first aid and other limited services to an inpatient. The term is mostly used when a patient experiences an abrupt illness or accident that is considered not so demanding but needs good moment of rest and care for a short period of time.

Care

Attention given to ensure safety of a patient. It is the general term describing the services rendered by a practitioner especially nurses, to patients. The term is used always whenever a patient is in the hospital to indicate that the patient is safe and no concerns should be raised about the health condition. In a scenario where the patient is leaving the hospital, the concerned persons are advised to care for the patient. Care therefore involves diagnosis of a problem and taking the responsibility to address the problem.

Capitation

The term means a fixed compensation method or payment for given health services done to a healthcare provider irrespective of the number of services rendered on the insured population. This term is usually used in regard to a given insuring body or company that reimburses or pays for medical services to a patient.

References

Health Information Careers: Glossary of Terms. Web.

Miller B.F. and Keane R.N. Encyclopedia and Dictionary of Medical, Nursing and Allied Health; 2nd ed. W.B Saunders Company, Philadelphia.