Reference Application - Glossary

Admission

An encounter created when a patient is admitted to the hospital.

Discharge

An encounter created when a patient is being released from the hospital.  In many cases, discharge orders (a discharge encounter) begins the process of discharging the patient from the hospital and a separate departure event actually ends the hospital visit.  In simple cases and for some implementations –especially before we have orders being entered in the system – this discharge encounter may be used to indicate the end of the hospital visit.

Disposition

The disposition for an encounter specifies "what should happen with the patient following the current encounter."  In some cases, the disposition might "Admit to Hospital"; in other cases, implementations might use the disposition to specify when the patient should follow up.

Clinical Encounter

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.

Visit

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 clinics on Friday, has a normal outpatient consultation, then goes home. He has a visit that spans a single hour or part of one day.
Example 2: Harriet arrives at the hospital on Friday, is admitted, and then is discharged the following Wednesday. She has an inpatient visit that spans five days.

Medical Record

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

Chart

Paperwork from a single visit.

Filing

Returning chart to a medical record, or returning a medical record to the shelf

Entering

Adding data from a chart or paper medical record to the electronic medical record