Term
| Elecronic Health Record (EHR) |
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Definition
| An entire health system that documents health care services and the information gathered to make decisions about health care. |
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Term
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Definition
| national standards group that defined approximately 130 different functions that electronic health record systems should be able to perform. |
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Definition
| government agencies, voluntary groups, and industry associations involved in establishing guidelines to assist in bringing uniformity to business processes or products. |
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Definition
| automated notices to practioners of information that requires immediate or special attention. |
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Definition
| electronic holding place for data |
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Definition
| systems that can communicate and exchange information with one another |
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Definition
| automated notices to practioners or patients regarding actions that need to be taken |
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Term
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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 |
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Definition
| Established guidelines for treatment of specific diseases |
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Term
| Health Information Exchange (HIE) |
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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 |
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Term
| National Health Information Network (NHIN) |
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Definition
| national system under development that will permit electronic sharing of health care data among those involved in care provision across the U.S. |
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| Regional Health Information Organizations (RHIOs) |
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Definition
| network of regional health care providers established forelectronic sharing of patient health care data |
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Term
| Application Service Provider (ASP) |
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Definition
| a vendoe or hospital health care system that hosts the EHR technology whole a practice pays or rents its use |
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Term
| Centers for Medicaid and Medicare Services (CMS) |
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Definition
| federal government office that oversees the Medicare and Medicaid programs |
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Term
| Certification Commission for Healthcare Information Technology (CCHIT) |
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Definition
| an independent, nonprofit organization formed to establish functional, interoperability and security crieteria and to certify EHR products as meeting those criteria |
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Term
| Quality Improvement Organization (QIO) |
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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 |
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Term
| Application Service Provider (ASP) Architecture |
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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 |
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Term
| Client Server Architecture |
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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 |
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Term
| Human- Computer Interface (user) Devices |
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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) |
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Term
| Current Procedural Technology-4th Revision (CPT-IV) |
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Definition
| coding nomenclature used for billing and public health reporting by ambulatory care service providers |
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Term
| International Classification of Diseases-9th Revision- Clinical Modification (ICD-9-CM) |
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Definition
| international coding classification system used for billing and public health reporting in all types of health care facilites |
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Term
| North American Nursing Diagnosis Association (NANDA) |
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Definition
| nursing terminology standard applied to nursing diagnoses |
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Term
| Nursing Interventions Classifications (NIC) |
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Definition
| nursing terminology standard applied to nursing interventions |
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Term
| Nursing Outcomes Classification (NOC) |
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Definition
| nursing terminology standard applied to patient outcomes |
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Term
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Definition
| defined area where a specific piece of information can be entered |
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Term
| Structured (discrete) Data |
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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 |
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Term
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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 |
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Definition
| a form of unstructured data not reflected in the EHR's data dictionary |
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Term
| Administrative Safeguards |
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Definition
| assignment of security management, security training, and delevoping policies and procedures |
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Definition
| routine system of tracking of all activity related to each patient's record in the EHR by user and role |
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Definition
| digitized (digital) images |
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Definition
| mechanisms that protect the equipment and the data associated with the EHR system |
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Definition
| automated processes that limit who is able to access the EHR and what they are able to do within the system |
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Definition
| patient record in which material is organized by type of recording |
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Definition
| patient content in which content is organized by the type of health professional entering data |
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Definition
| documentation in a patient's record that is not related to care or treatment provided; includes demographic, financial, and consent information |
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Definition
| Components of a patient's record that relate to the care and treatment provided to the patient |
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Term
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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 |
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Term
| American Osteopathic Association (AOA) |
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Definition
| one of a number of voluntary organizations providing standards for and evaluating care in ambulatory care facilities, labrotories, amd ambulatory surgery settings |
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Term
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Definition
| a joint state/federal funded program providing health care benefits to populations below a defined income level |
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Definition
| national program to provide federally funded health care assistance to the elderly in the United States |
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Term
| Conditions of Participation or Conditions of Coverage |
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Definition
| general name for the regulations that care providers must meet inorder to participate in the Medicare/Medicaid programs |
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Term
| Joint Commission "Do Not Use" Abbreviation List |
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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 |
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Term
| Master Patient/Person Index (MPI) |
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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 |
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Term
| Practice Management System (PMS) |
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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 |
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Definition
| one longitudinal record for each individual no matter how many times the individual has been seen by an organization (or organizations) |
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Definition
| authorization by the patient for a third-party payer to directly reimburse the practice (instead of the patient) for services provided |
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Definition
| touching an individual without consent |
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Term
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Definition
| documentation signed by the patient giving approval to the provision of routine care |
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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 |
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Term
| Notice of Privacy Practices |
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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 |
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| Durable Power of Attorney |
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Definition
| type of advance directive givng another person the right to make health care decisions for the patient |
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Term
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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 |
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Term
| Authorizations for Release (disclosure) of Information |
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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 |
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Term
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Definition
| lists of significant diagnoses procedures, drug allergies, and medications that the Joint Commission requires ambulatory patient records to contain |
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Definition
| summary list of all patient allergies known to the practice |
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Definition
| summary list of all the medications a patient has taken or is currently taking |
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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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