Electronic Health Record Systems
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| process of identifying source of HR entries by handwritten signature, author's initials or an electronic signature | authentication
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| software & hardware located at patient's bedside that encourages recording of info about patient care at or near time it is delivered | bedside documentation systems
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| collects, organizes, & analyzes all institutional business & clinical data that have been summarized & aggregated for that purpose | clinical data repository
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| specific procedures/protocols for medical professionals to follow for patients w/particular diagnosis/medical condition based on research | clinical practice guidelines
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| scheme for grouping similar things in logical way, based on common aspects; vary in level of detail enabling users to capture lrg amounts of specific, or granulary, data | classification system
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| term to describe patient record system that could be part of hospital info sys., medical info sys., or type of clinical info system. | computer-based patient record
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| ethical/legal concept endorsed by health professionals to meet expectation of patients that their info, when provided to auth. user, will not be redisclosed/misused | confidentiality
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| clinical data repositories are designed to deliver individual patient's info to care team through | clinical workstations
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| central repository for all info about database functions as catalog for identifying nature of all data in a system | data dictionary
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| rules that are applied to data to trigger an outcome i.e. create an alert in an EHR | data-driven rules
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| agreed on means of transmitting data & connecting data communications equipment | data interface standards
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| technical, physical, & procedural methods by which access to confidential info is controlled & managed | data security
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| receive clinical data from transactions system & combine them with other organizational data from administrative & financial systems | data warehouses
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| contains info; may be in a physical or virtual format | document
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| electronic health care record
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| electronic health record
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| event engine
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| health care information
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| health informatics
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| information warehouses
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| data dictionary provides central resource for ensuring that standard definitions for ___ ___ & ___ are used throughout the system | data elements & structures
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| typically product of standards development organization & is recognized by the American National Standards Institute | formal data interface standards
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| data warehouses are also referred to as | information warehouses
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| infrastructure
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| internet
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| knowledge
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| multimedia
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| natural language processing
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| nonrepudiation
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| niche vendors
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| patient record
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| patient record system
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| primary patient record
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| privacy
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| registration admission
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| registration discharge
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| registration transfer
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| script-based systems
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| secondary patient record
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| template
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| text processing
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| vocabularies
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Created by:
lfrancois
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