/depts/,/depts/uwhealth/,/depts/uwhealth/him/,/depts/uwhealth/him/fileroom/,/depts/uwhealth/him/fileroom/commonly-used-terms/,

/depts/uwhealth/him/fileroom/commonly-used-terms/

201407197

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UWHC,

Medical Records,

Departments & Programs,UW Health,Health Information Management,HIM File Room/Document Imaging

Commonly Used Terms

Commonly Used Terms - Departments & Programs, UW Health, Health Information Management, HIM File Room/Document Imaging

Focus

Archived Sending records to storage when they have been inactive for a set amount of months
Box Number A unique identifier that is used to determine a chart's location at the State Record Center
Deficient Charts that are requested, but still out to another borrower
Delinquent Discharges that do not contain the required elements to declare the stay "complete," such as a signed discharge summary, op report or outpatient face sheet. A discharge is considered delinquent 14 days post-discharge.
Delivery The act of physically transporting charts to the requesting location
Discharge Conclusion of an inpatient stay 
Discharge

Summary

Dictated notes by the attending physician, or resident, sumarizing the inpatient hospital course
Document Imaging Process of converting documentation/data into a digital format housed in the EMR/EFC.
Drop File Filing the loose elements inside the front cover of the record
EFC: Electronic File Cabinet Documents viewable and stored only through OnBase application.
Identity-Double Number Patient has two or more medical record numbers.
Identity-Fraud The investigation of potential fraudulent activity.
Identity-Overlay Documentation for one patient is entered into another patient’s record.
Issue The act of transfering responsibility of a chart to the requesting borrower via Health Link
Loose Elements Any documents which are received by the file room, sorted and drop filed into appropriate patient's record within 72 hours.
Maintenance Refers to loose elements being two-hole punched and filed under proper tab in the chart prior to issuing
OnBase Software used for document scanning/capture which interfaces with Health Link.
Operative

Note

Dictated note by the surgeon describing an operation preformed on a patient. These are also refered to as "op notes."
Patient Death Indicator A field in Health Link that identifies if a patient has passed away
Paper Chart Physical chart holding documentation that has not been converted to EMR/EFC.
Permanent Station The code used in Health Link to indicate where a patient's medical record is stored
   
Rush Request A request for a chart needed within 24 hours for patient care
Scanned

Document

Any approved internal or external document/form received by HIM and scanned into the EMR.
Terminal

Digit

Numerical filing system used at all locations that house charts
Transfer Line 203-4597 - a phone number to call and leave a message that a chart has been transferred to another location
Volumes Individual folders that make up the complete record for a patient