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Chapter5
| Term | Definition |
|---|---|
| Character | Smallest piece of data |
| Clinical data Repository | the merging of data from different data systems into one centralized database |
| 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. |
| Computerized medical record | used to describe the early medical record automation attempts |
| Data | is defined as raw facts that are not interpreted or processed, such as numbers, letters, images, symbols and sounds |
| Document imaging/ Optical disk imaging | an alternative to traditional microfilm or remote storage systems |
| EHR | a term used in 2003 by IOM. |
| EMR | Term used in 1990s to describe systems that were based on imaging and the merging of data from various stand-alone systems. |
| Field | Group of characters |
| File | Collection of related records |
| Health data | Health facts that are collected about a patient or group of patients that describe a health issue |
| 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 |
| HIE- Health information exchange | Allow health care providers the opportunity to access patent information that was generated at other facilities |
| HL7- Health Level 7 | a standards development organization that develops EHR standards under the direction of the U.S DHHS |
| Hybrid records | a part paper and part electronic record |
| Indexed | means it is identified according to a unique identification number, commonly the patients medical record # |
| Information | After data has been collected it is given meaning and is useful for decision making |
| 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 |
| Patient monitoring system | systems that collect and monitor patient physiological data and record the informaiton |
| PHR- Patient health record | an electronic or paper medical record maintained and updated by an individual for his or her own personal use |
| Record | collection of related fields |
| Record transitional template | a type of document that delineates the carious sources of the component parts of the patients record |
| RHIO- Regional health information organization | an electronic network of patient medical information gathered from multiple health care organizations in a geographical region |
| 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 |
| Scanner | Used to capture paper record images onto electronic storage media |