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Healthcare Med Rec 2

Medical Terminology

TermDefinition
electronic health records (EHRs) health records that allow real-time communication, reporting, and record keeping through electronic transmission
hybrid health records medical records that incorporate elements of paper-based records and electronic records
source-oriented medical record a record that is organized by data source or subject
problem-oriented medical record a record that organizes data by problem, and uses four categories: a database of all objective information, a numbered problem list, initial treatment plans, and progress notes
clinical data repository (CDR a special database that manages healthcare data from different sources such as labs, pharmacies, and radiology networks
electronic medication administration record (EMAR) an EHR system for medication management that uses the CDR database
patient care charting system a type of EHR that records progress notes and assessments
hospital information system (HIS) a computerized management solution that handles all aspects of a hospital’s operations, including financial and medical operations
Certification Commission for Health Information Technology (CCHIT) a nonprofit organization with the mission of accelerating the adoption of information technology (IT) in healthcare, it measures and certifies the effectiveness of EHR products based on predefined criteria
pay for performance (P4P) performance-oriented incentives for hospitals and physicians to improve the quality of patient healthcare
Centers for Medicare and Medicaid Services (CMS) a US government organization that oversees services for the federally sponsored Medicare and Medicaid insurance programs
Dental Office Reference Manual (DORM) a reference manual that provides information about administrative policies relating to a dental practice
Dental Periodicity Schedule a schedule that recommends certain oral health services for children according to age
dental extraction the removal of primary teeth
Created by: rleroux