EHR Exam Terminology Flashcards

Health Care
Terms Definitions
Imaged Data
digitized (digital) images
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
preformatted data collection screens containing specific structured and/or free-text data fields and designed to support efficient and complete documentation
automated notices to practioners or patients regarding actions that need to be taken
national program to provide federally funded health care assistance to the elderly in the United States
Summary Lists
lists of significant diagnoses procedures, drug allergies, and medications that the Joint Commission requires ambulatory patient records to contain
systems that can communicate and exchange information with one another
software developed to review claims for discrepancies or errors and to validate complance with regulatory mandated prior to submision to third-party payers
Drug Vocabularies
national terminologies associated with pharmacy information systems to support accurate communication of prescriptiopns and assure correct drug labeling
Free-Text Narrative
unstructured documentation that allows a practitioner to dictate or key text
Unit Record
one longitudinal record for each individual no matter how many times the individual has been seen by an organization (or organizations)
Living Will
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
Encounter Form
preprinted paper template designed to record the diagnoses and procedures completed during an office visit along with their ICD and/or CPT codes
Patient Portal
secure internet connection to a practice for communicationand access to practice databases by patient's
Certification Commission for Healthcare Information Technology (CCHIT)
an independent, nonprofit organization formed to establish functional, interoperability and security crieteria and to certify EHR products as meeting those criteria
Allergy List
summary list of all patient allergies known to the practice
Nursing Outcomes Classification (NOC)
nursing terminology standard applied to patient outcomes
Source-Oriented Record
patient content in which content is organized by the type of health professional entering data
Clinical Data
Components of a patient's record that relate to the care and treatment provided to the patient
Graphic Displays
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
Classification Setting
a system that groups similar diagnoses or procedures together for reporting purposes
Procedure Notes Template
structured format documentation by a health carw provider describing the patient encounter
Growth Chart
graphic display of the height and weight of pediatric patients comparing their data to a development standard for the patient's age group
Medication List
summary list of all the medications a patient has taken or is currently taking
Quality Improvement Organization (QIO)
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
Current Procedural Technology-4th Revision (CPT-IV)
coding nomenclature used for billing and public health reporting by ambulatory care service providers
North American Nursing Diagnosis Association (NANDA)
nursing terminology standard applied to nursing diagnoses
Narrative Text Data
a form of unstructured data not reflected in the EHR's data dictionary
Computer Assisting Coding (CAC)
use of coding software that automatically generates medical codes based on documentation in the patient record
Medication (drug) Reference Information
published texts that provide details on drugs approved for use in the United States; often available in hardcopy or via software
Centers for Medicaid and Medicare Services (CMS)
federal government office that oversees the Medicare and Medicaid programs
National Health Information Network (NHIN)
national system under development that will permit electronic sharing of health care data among those involved in care provision across the U.S.
Point of Care
the time at which treatment is being provided
E-Mail and Electronic Text Messages
scripted messages entered on one computer, cell phone, or PDA and then sent to another computer or receiving device
Order Format and Details(order sentence)
general sequence for the detailed information passed from prescribing provider to the pharmacy
Master Patient/Person Index (MPI)
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
Medication (drug) Alerts and Reminders
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
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