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EHR Exam 1 Terminology
Electronic Health Record
60
Health Care
Undergraduate 1
10/20/2009

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Term
Elecronic Health Record (EHR)
Definition
An entire health system that documents health care services and the information gathered to make decisions about health care.
Term
Health Level Seven (HL7)
Definition
national standards group that defined approximately 130 different functions that electronic health record systems should be able to perform.
Term
Standards Organizations
Definition
government agencies, voluntary groups, and industry associations involved in establishing guidelines to assist in bringing uniformity to business processes or products.
Term
Alerts
Definition
automated notices to practioners of information that requires immediate or special attention.
Term
Data Repository
Definition
electronic holding place for data
Term
Interoperable
Definition
systems that can communicate and exchange information with one another
Term
Reminders
Definition
automated notices to practioners or patients regarding actions that need to be taken
Term
Telemonitoring
Definition
using telecommunications technology to gather physiolgic or diagnostic data and transmit it to a health care provider who can evaluate patients who are located a distance from the care provider setting
Term
Treatment Protocols
Definition
Established guidelines for treatment of specific diseases
Term
Health Information Exchange (HIE)
Definition
national, regional, or local efforts established for electronic sharing of patient health care data among care providers ; subdivisions of the NHIN that may also be referred to as SNO's
Term
National Health Information Network (NHIN)
Definition
national system under development that will permit electronic sharing of health care data among those involved in care provision across the U.S.
Term
Regional Health Information Organizations (RHIOs)
Definition
network of regional health care providers established forelectronic sharing of patient health care data
Term
Application Service Provider (ASP)
Definition
a vendoe or hospital health care system that hosts the EHR technology whole a practice pays or rents its use
Term
Centers for Medicaid and Medicare Services (CMS)
Definition
federal government office that oversees the Medicare and Medicaid programs
Term
Certification Commission for Healthcare Information Technology (CCHIT)
Definition
an independent, nonprofit organization formed to establish functional, interoperability and security crieteria and to certify EHR products as meeting those criteria
Term
Quality Improvement Organization (QIO)
Definition
an organization that contracts with the federal government to perform tasks on its behalf under the Medicare program, focusing especially on quality and necessity of care issues; these organizations also administer the DOQ-IT programs
Term
Application Service Provider (ASP) Architecture
Definition
one of two models for constructing a practice EHR; access to the EHR system is made through a secured internet portal into a vendor-maintained and vendor-managed data center referred to as a "remote site", reducing the hardware and up-front costs for the practice
Term
Client Server Architecture
Definition
one of two models for constructing a practice EHR; anannual licensing fee is paid to the EHR vendor for use of software, but all other components of the system are owned, operated, and maintained by the practice
Term
Human- Computer Interface (user) Devices
Definition
the devices by which practice personnel interact with the EHR system; examples include wall mount or desktop computers, laptop computers, notebook or tablet personal computers, and personal digital assistants (PDAs)
Term
Current Procedural Technology-4th Revision (CPT-IV)
Definition
coding nomenclature used for billing and public health reporting by ambulatory care service providers
Term
International Classification of Diseases-9th Revision- Clinical Modification (ICD-9-CM)
Definition
international coding classification system used for billing and public health reporting in all types of health care facilites
Term
North American Nursing Diagnosis Association (NANDA)
Definition
nursing terminology standard applied to nursing diagnoses
Term
Nursing Interventions Classifications (NIC)
Definition
nursing terminology standard applied to nursing interventions
Term
Nursing Outcomes Classification (NOC)
Definition
nursing terminology standard applied to patient outcomes
Term
Data Field
Definition
defined area where a specific piece of information can be entered
Term
Structured (discrete) Data
Definition
data fields where either numbers or dates must be entered or in which a selection from a defined list of options must be made
Term
Data Dictionary
Definition
a listing of each data field ina system; fields are defined by a unique title or label, an indication of the type of data, a functional description, and a standard format
Term
Narrative Text Data
Definition
a form of unstructured data not reflected in the EHR's data dictionary
Term
Administrative Safeguards
Definition
assignment of security management, security training, and delevoping policies and procedures
Term
Audit Trails
Definition
routine system of tracking of all activity related to each patient's record in the EHR by user and role
Term
Imaged Data
Definition
digitized (digital) images
Term
Physical Safeguards
Definition
mechanisms that protect the equipment and the data associated with the EHR system
Term
Technical Safeguards
Definition
automated processes that limit who is able to access the EHR and what they are able to do within the system
Term
Integrated Record
Definition
patient record in which material is organized by type of recording
Term
Source-Oriented Record
Definition
patient content in which content is organized by the type of health professional entering data
Term
Administrative Data
Definition
documentation in a patient's record that is not related to care or treatment provided; includes demographic, financial, and consent information
Term
Clinical Data
Definition
Components of a patient's record that relate to the care and treatment provided to the patient
Term
Ambulatory Care
Definition
the health care category of patients who are not admitted to occupy a bed but rather seek health care services usually in the provider's office setting; the patient physically moves to the provider's location in order to receive care
Term
American Osteopathic Association (AOA)
Definition
one of a number of voluntary organizations providing standards for and evaluating care in ambulatory care facilities, labrotories, amd ambulatory surgery settings
Term
Medicaid
Definition
a joint state/federal funded program providing health care benefits to populations below a defined income level
Term
Medicare
Definition
national program to provide federally funded health care assistance to the elderly in the United States
Term
Conditions of Participation or Conditions of Coverage
Definition
general name for the regulations that care providers must meet inorder to participate in the Medicare/Medicaid programs
Term
Joint Commission "Do Not Use" Abbreviation List
Definition
Joint Commission's list of medical abbreviations that cause errors in interpretation and hence should not be found in the patient documentation of facilities that desire their accreditation
Term
Master Patient/Person Index (MPI)
Definition
the key to locating a patient record, this listing includes patient identifying information and the assigned record number for all individuals ever receiving care by an organization
Term
Practice Management System (PMS)
Definition
system that supports the financial and administrative functions of a practice; usually includes patient's demographics, appointment scheduling, charge capture and billing, and report generation
Term
Unit Record
Definition
one longitudinal record for each individual no matter how many times the individual has been seen by an organization (or organizations)
Term
Assignment of Benefits
Definition
authorization by the patient for a third-party payer to directly reimburse the practice (instead of the patient) for services provided
Term
Battery
Definition
touching an individual without consent
Term
Consent for Treatment
Definition
documentation signed by the patient giving approval to the provision of routine care
Term
Advance Directive
Definition
document that provides guidance to practitioners about the wishes of a patient should he or she become incapacitated or no longer able to make decisions because of medical or psychiatric impairment
Term
Notice of Privacy Practices
Definition
information that HIPAA requires be provided to patients about the use and disclosure of information by the practice, patient rights and responsibilities in relation to the record, and contact information should questions arise
Term
Durable Power of Attorney
Definition
type of advance directive givng another person the right to make health care decisions for the patient
Term
Living Will
Definition
type of advance directive that outlines the wishes of the patient in relation to medical care in life threatning situations; it may also name a represenative
Term
Authorizations for Release (disclosure) of Information
Definition
Document completed and signed by the patient (or the patient's represenative) to permit the sharing of confidential patient information with others for any purpose other than treatment, health cre payment, or health care operations
Term
Summary Lists
Definition
lists of significant diagnoses procedures, drug allergies, and medications that the Joint Commission requires ambulatory patient records to contain
Term
Allergy List
Definition
summary list of all patient allergies known to the practice
Term
Medication List
Definition
summary list of all the medications a patient has taken or is currently taking
Term
Problem List
Definition
summary list of all the major diagnoses that a patient has experienced and been treated for by a health care practice
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