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advance directive
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legal document that lists the patient’s wishes regarding life-sustaining medical treatments
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age of majority
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defined by each U.S. state as the age at which one can make their own decisions, including health-care decisions
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alternative substance
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nonregulated herbal substance or homeopathic medication
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chief complaint
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statement of the signs and symptoms that have led the patient to seek medical attention
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collaborative problem
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a certain physiological response the nurse monitors that can be addressed through nursing intervention and physician-prescribed treatments
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demographic data
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identifying basic patient information
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electronic health record (EHR)
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digital format of a patient’s chart that contains data related to the patient’s medical history, diagnoses, medications, treatment plans, immunization dates, allergies, radiology images, and laboratory and test results
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electronic medical record (EMR)
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single facility’s digital version of a patient’s chart
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familial disease
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disease that tends to occur often in particular families
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health information exchange (HIE)
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vehicle for doctors, nurses, patients, and other interdisciplinary healthcare members to access and securely share critical healthcare information electronically, improving the speed, quality, safety, and cost of patient care
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Health Information Technology for Economic and Clinical Health (HITECH) Act
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a law that promotes meaningful ways to incorporate health information technology while still protecting patients’ privacy rights
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Health Insurance Portability and Accountability Act(HIPAA)
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law that details national standards for electronic healthcare transactions and protection of privacy for health information
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health record
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collection of subjective and clinical information pertaining to a patient’s physical and mental health, compiled from a variety of sources
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healthcare informatics
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field that incorporates health care and computer and information sciences
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hereditary disease
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disease passed down from generation to generation
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initial health assessment
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systematic and purposeful collection and analysis of patient information
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interoperability
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the ability to share patient information across multiple healthcare systems in digital format
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meaningful use
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using electronic health information in a meaningful way to improve patient care
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medical power of attorney
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legal document that outlines who can make medical decisions on behalf of the patient in the event they cannot do so themselves
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minimum data set (MDS)
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standard established by healthcare institutions that specifies the information that must be collected from every patient
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nursing diagnosis
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clinical judgment based on the medical diagnosis of a patient that helps the nurse determine the plan of care
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objective data (also, signs)
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information observed through your senses of hearing, sight, smell, and touch while assessing the patient
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over-the-counter medication
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medication that does not require a prescription
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Patient Care Partnership
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document that tells the patient what to expect while receiving medical care under the organization and outlines their rights; formerly called a Patient Bill of Rights
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physical finding
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the assessment of a body system
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primary source
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the patient
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secondary source
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information obtained from the history section of the health record, or the patient’s family
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signs (also, objective data)
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information observed through your senses of hearing, sight, smell, and touch while assessing the patient
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subjective data (also, symptom)
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information obtained from the patient and/or family members and can provide important cues about functioning and unmet needs requiring assistance
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subpoena duces tecum
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court order to produce documents or records
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symptom (also, subjective data)
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information obtained from the patient and/or family members and can provide important cues about functioning and unmet needs requiring assistance
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treatment plan
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used to increase patient outcomes related to a specific disease or condition
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usability
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extent to which a product can be used by specified users to achieve specified goals with effectiveness, efficiency, and satisfaction in a specified context of use
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vital sign
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a marker of physiological homeostasis and essential in the analysis of monitoring patient progress; obtained by measuring body temperature, pulse, respiratory rate, and blood pressure