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Term: Clinical Encounter
Explanation: An interaction between a patient and a healthcare provider at a particular place and time. Every clinical encounter has a disposition.
Example: In one day, John sees Nurse Jackie to have his vitals taken, sees Doctor Michelle for a general consultation, has his blood drawn by Lab Tech George, and returns to see Doctor Michelle to get the results. John has four encounters, one with Jackie, two with Michelle, and one with George.
Explanation: An episode of care for a patient at a hospital that encompasses one or more encounters, beginning when the patient arrives, and ending when the patient leaves or is otherwise discharged.
Example 1: John arrives at the hospital on Friday, has a normal outpatient consultation, then goes home. He has a visit that spans one day.
Example 2: Harriet arrives at the hospital on Friday, is admitted, and then is discharged the following Wednesday. She has a visit that spans five days.
Term: Medical Record
Explanation: Full set of all charts and forms from all visits for one patient. Has a identifier unique to the Hospital. Patient has a paper medical record and an electronic medical record
Explanation: Paperwork from a single visit.
Explanation: Returning chart to a medical record, or returning a medical record to the shelf
Explanation: Adding data from a chart or paper medical record to the electronic medical record