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Chapter5

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Term
Definition
Character   Smallest piece of data  
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Clinical data Repository   the merging of data from different data systems into one centralized database  
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Computer-based patient record   was used to describe a broader view of the patient record than was present in 1990s. MULTIDISCIPLINARY AND MULTIENTERPRISE. Has the ability to link patient information at different locations according to a unique patient identifier.  
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Computerized medical record   used to describe the early medical record automation attempts  
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Data   is defined as raw facts that are not interpreted or processed, such as numbers, letters, images, symbols and sounds  
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Document imaging/ Optical disk imaging   an alternative to traditional microfilm or remote storage systems  
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EHR   a term used in 2003 by IOM.  
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EMR   Term used in 1990s to describe systems that were based on imaging and the merging of data from various stand-alone systems.  
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Field   Group of characters  
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File   Collection of related records  
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Health data   Health facts that are collected about a patient or group of patients that describe a health issue  
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Health information   defined as health data that has been given meaning and has been processed or organized in a manner that us useful for decision making  
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HIE- Health information exchange   Allow health care providers the opportunity to access patent information that was generated at other facilities  
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HL7- Health Level 7   a standards development organization that develops EHR standards under the direction of the U.S DHHS  
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Hybrid records   a part paper and part electronic record  
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Indexed   means it is identified according to a unique identification number, commonly the patients medical record #  
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Information   After data has been collected it is given meaning and is useful for decision making  
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Longitudinal patient record   Contains records from different episodes of care, providers, and facilities that are linked to form a view, over time, of a patients health care encounters  
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Patient monitoring system   systems that collect and monitor patient physiological data and record the informaiton  
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PHR- Patient health record   an electronic or paper medical record maintained and updated by an individual for his or her own personal use  
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Record   collection of related fields  
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Record transitional template   a type of document that delineates the carious sources of the component parts of the patients record  
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RHIO- Regional health information organization   an electronic network of patient medical information gathered from multiple health care organizations in a geographical region  
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RADT- Registration, Admission, discharge, transfer   an application that creates a centralized database of patient demographic information and has replaced the paper master patient index in the virtual world  
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Scanner   Used to capture paper record images onto electronic storage media  
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