Term
|
Definition
| beginning with the chief complaint, a standard set of examinationsteps that will specifically eliminate, or specifically confirm, potential underlying causes for the chief complaint |
|
|
Term
|
Definition
| the time at which treatment is being provided |
|
|
Term
|
Definition
| preformatted data collection screens containing specific structured and/or free-text data fields and designed to support efficient and complete documentation |
|
|
Term
|
Definition
| unstructured documentation that allows a practitioner to dictate or key text |
|
|
Term
|
Definition
| a format for presenting numerical data that has been entered into structured (coded) data fields,showing trends in clinical data and allowing comparisons over time |
|
|
Term
|
Definition
| graphic display of the height and weight of pediatric patients comparing their data to a development standard for the patient's age group |
|
|
Term
|
Definition
| designation of work that needs to be completed during scheduled hours by an employee of a practice |
|
|
Term
|
Definition
| a final component of an assessment which specifies any number and variety of actions needed to appropriately address the patient's health care problem(s). In a SOAP note it is the content in the "P" section of the documentation |
|
|
Term
|
Definition
| transfer of health care provider information from one organization to nothe via facsimile transmission |
|
|
Term
| Electronic Data Interchange (EDI) |
|
Definition
| transfer of health care provider information from one organization to another electronically |
|
|
Term
|
Definition
| specific items that must be entered by a health care provider to make an order complete |
|
|
Term
|
Definition
| the format of structured data entry items required to complete a medical order |
|
|
Term
|
Definition
| structured format documentation by a health carw provider describing the patient encounter |
|
|
Term
|
Definition
| communications of the findings associated with a completed diagnostic test order |
|
|
Term
|
Definition
| national terminologies associated with pharmacy information systems to support accurate communication of prescriptiopns and assure correct drug labeling |
|
|
Term
| Medication (drug) Reference Information |
|
Definition
| published texts that provide details on drugs approved for use in the United States; often available in hardcopy or via software |
|
|
Term
| Order Format and Details(order sentence) |
|
Definition
| general sequence for the detailed information passed from prescribing provider to the pharmacy |
|
|
Term
| Medication (drug) Alerts and Reminders |
|
Definition
| messages sent to a health care provider that call attention to any potential adverse effects that ould result if the intended medication order is carried out |
|
|
Term
| Health Maintenance Reminder |
|
Definition
| a reminder given to a health care provider and/or a patient by the provider, calling attwntion to maintaining the patient's health status |
|
|
Term
| Telephone (voice mail) Patient Messages |
|
Definition
| messages recorded by voice over the telephone when the person or practice called cannot or does not answer the call |
|
|
Term
| E-Mail and Electronic Text Messages |
|
Definition
| scripted messages entered on one computer, cell phone, or PDA and then sent to another computer or receiving device |
|
|
Term
|
Definition
| secure internet connection to a practice for communicationand access to practice databases by patient's |
|
|
Term
| Explanation of Benefits(EOB) or Remittance Advice (RA) |
|
Definition
| communication from a third-party payer to a practice indicating payment for services, claim problems for follow-up action, or non-coverage of services |
|
|
Term
|
Definition
| coding systems; a term particularly used for those approved by HIPAA regulations for use in electronic transactions |
|
|
Term
| Healthcare Common Procedure Coding Systems (HCPCS) |
|
Definition
| coding system designated by HIPAA for electronic transactions relating to procedures performed in the ambulatory setting |
|
|
Term
|
Definition
| a system that groups similar diagnoses or procedures together for reporting purposes |
|
|
Term
|
Definition
| represenatives from four organizations that together make reccomendations for ICD-9-Cm code modifications and additions |
|
|
Term
|
Definition
| software with current coding classification systems embedded to assist with the coding process |
|
|
Term
|
Definition
| preprinted paper template designed to record the diagnoses and procedures completed during an office visit along with their ICD and/or CPT codes |
|
|
Term
|
Definition
| the linking of content from one terminology or classification system to another |
|
|
Term
|
Definition
| a listing of coding terms |
|
|
Term
| Computer Assisting Coding (CAC) |
|
Definition
| use of coding software that automatically generates medical codes based on documentation in the patient record |
|
|
Term
| Natural Language Processing |
|
Definition
| software that applies artificial intelleigence to narrative text in order to extract terms and data |
|
|
Term
| National Provider Identifier (NPI) |
|
Definition
| a national identifying number assigned to a health care provider to use with HIPAA transactions, including medical billing |
|
|
Term
|
Definition
| software developed to review claims for discrepancies or errors and to validate complance with regulatory mandated prior to submision to third-party payers |
|
|
