Medical Records Archivist Glossary

by , under field-related glossaries, Vocabulary

Where do your medical records go when you leave the hospital? Ask a medical records archivist. All that stuff gets coded and filed away for quick access by medical professionals. Learn the specialized vocabulary used by medical archivists with this handy glossary of terms.

Medical archivist
U.S. Navy photo by Rod Duren [Public domain]
active records
Frequently used records required for day-to-day business, referred to more than once per month per file drawer.
administrative officer
Administrative officers oversee and implement administrative procedures, establish work priorities and co-ordinate the acquisition of administrative services such as office space, supplies and security services.
alphabetical
In the order of the letters of the alphabet.
alphanumeric order
Arranged in the following order: blanks, special characters, numerals (single digits before double digits), and then letters.
ambulatory care
A personal health care consultation, treatment, or intervention using advanced medical technology or procedures delivered on an outpatient basis.
appraisal
The process of determining the value of records based on administrative, fiscal, and legal value; their evidential and informational value.
archives
A collection of records providing information about a place, institution, or group of people, preserved for their enduring value.
archivist
A person whose primary duties consist of appraising, describing, referencing, and caring for archival records.
arrangement
The relationship of individual files within a record series to each other, such as alphabetical, numerical, alphanumerical, or chronological.
Canada Health Infoway
A strategic investor, who works with Canadian provinces and territories with the goal of creating an electronic health record for 50% of Canadians.
chronological
In an order starting with the earliest date and following and continuing in the order in which they occurred.
computer
General purpose device that can be used with software to carry out a set of arithmetic or logical operations.
computer output microfilm (COM)
The conversion of electronic data directly onto microfilm.
confidentiality
A set of rules or a promise that limits access or places restrictions on certain types of information.
consent
Agreement or permission to do or allow something.
coroner
A government official who confirms and certifies the death of an individual within a jurisdiction.
court
A judicial tribunal duly constituted for the hearing and determination of cases.
conversion of records formats
Transferring records from one format to another, including changing paper to microform, optical disk, or another electronic format.
custody
The protective care or guardianship of records and manuscripts which may include both physical possession and legal title.
data collection
The process of gathering and measuring information on variables of interest, in an established systematic fashion that enables one to answer stated research questions, test hypotheses, and evaluate outcomes.
designation
The primary classification given to a series of records based on governmental review.
diagnosis
The identification of the nature and cause of a certain phenomenon.
discharge summary
A clinical report prepared by a health professional outlining the patient’s chief complaint, the diagnostic findings, the therapy administered and the patient’s response to it, and recommendations on discharge.
disclosure
The release of information about a person or entity.
disease
An abnormal condition that affects the body of an organism. It is often construed as a medical condition associated with specific symptoms and signs.
doctor
A person, especially a physician, dentist, or veterinarian, trained in the healing arts and licensed to practice.
drug
A substance which may have medicinal, intoxicating, performance enhancing or other effects when taken or put into a human body.
duplicate
A working copy other than the master or security copy, scheduled to serve the same or shorter retention period than a master copy.
Epidemiology
The study of the patterns, causes, and effects of health and disease conditions in defined populations.
fax machine
A telephonic transmission of scanned printed material (both text and images), normally to a telephone number connected to a printer or other output device.
file
A kind of folder that holds loose papers together for organization and protection.
form
A printed document with blank spaces for information to be inserted.
health
The level of functional or metabolic efficiency of a living organism.
hospital
A health care institution providing patient treatment by specialized staff and equipment.
hospitalization
The act, process, or state of being hospitalized
hybrid system.
An information management system composed of microfilm and digital imaging.
inactive records
Records with a reference rate of less than one search per file draw per month.
information management
The collection and management of information from one or more sources and the distribution of that information to one or more audiences.
International Classification of Diseases
The standard diagnostic tool for epidemiology, health management and clinical purposes, used to monitor the incidence and prevalence of diseases and other health problems.
Jurisprudence
The study and theory of law.
master
The original from which duplicates are made.
medical coding
The process of transforming descriptions of medical diagnoses and procedures into universal medical code numbers.
medical record
The systematic documentation of a single patient’s medical history and care across time within one particular health care provider’s jurisdiction.
medicine
A field of applied science related to the art of healing by diagnosis, treatment, and prevention of disease.
normative
Used to describe the way something ought to be done according to a value position.
office
A room or other area where administrative work is done.
office chair
type of chair that is designed for use at a desk in an office.
patient
Any recipient of health care services, who is ill or injured and in need of treatment by a medical professional.
permanent records
Records that need continued retention due to their long-term administrative, legal, fiscal, or historical value.
photocopier
Machine that makes paper copies of documents and other visual images quickly and cheaply.
retention schedule
A document listing all the titles of the records series, length of time each document or record will be retained as an active record.
signature
A person’s name written in a distinctive way as a form of identification in authorizing a cheque or document or concluding a letter.
software
Non-tangible component of computers used with computer hardware to perform an operation.
statistics
The study of the collection, organization, analysis, interpretation and presentation of data.
strike off
To record that the patient has left the hospital; to remove from the list.
subpoena
A document that requires its recipient to appear in court as a witness.
telehealth
The delivery of health-related services and information via telecommunications technologies.
transcription
The conversion of voice-recorded reports dictated by healthcare professionals into text format.
trauma registry
A trauma registry is a system of timely data collection that aids in the evaluation of trauma care for a set of injured patients who meet specific criteria for inclusion.
Please follow and like us:
error