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Ch. 1 EHR Key Terms
vocabulary from Chapter 1
| Term | Definition |
|---|---|
| account ledger | lists services provided, payments made by the patient, reimbursement received from the patient's insurance company, adjustments, and outstanding amount owed. |
| audit | a review of employee activity within the EHR system, including an examination of which files were accessed or modified, when, and why. |
| chief complaint | the patient's stated primary reason for seeking treatment. |
| clinical decision support (CDS) | a set of patient-centered tools embedded within EHR software that can be used to improve patient safety, ensure that care conforms to published protocol for specific conditions, and reduce duplicate or unnecessary care and its associated costs. |
| computerized provider entry (CPOE) | an EHR function that allows a provider or provider-appointed licensed healthcare professional or credentialed medical assistant to enter the ordered medications and tests using an automated format. |
| continuity of care | a key aspect of quality that encompasses planning and coordination of care, communication among members of the healthcare team, and accessibility and transportability of information. |
| copayment | a fixed sum of money, dictated by the insurance company, that is paid by the patient, usually at the time medical services are rendered. |
| day sheet | a register for all daily business transactions such as patient services, payments, and adjustments; also called a day journal |
| documentation | the process of recording data about a patient's health history and status; the chronologic record that results from such data |
| electronic health record (EHR) | an electronic health record that allows for the management of a patient's health information by multiple providers |
| electronic medical record (EMR) | an electronic health record that allows the management of a patient's health information by authorized clinicians and staff members within a single healthcare organization. |
| electronic transcription | data entry into the EHR using handwriting recognition, voice recognition, electronic sentence building, scanning, and other means. |
| encounter | a documented interaction or visit between a patient and healthcare provider |
| interoperability | the ability of separate EHR systems to share information in compatible formats |
| Meaningful Use (MU) | part of the federal EHR Incentive Program; if providers can show that they have implemented and are using EHRs in specified meaningful ways, they will receive financial incentives from the government. |
| Office of the National Coordinator for Health Information Technology (ONCHIT) | Division of the Office of the Secretary, within the Department of Health and Human Services. Coordinates the effort to implement health information technology and the electronic exchange of health information. |
| patient information form | a form used to gather data about the patient, including basic demographic information, medical insurance data, and emergency contact. |
| practice management software (PMS) | software used in a medical office to accomplish administrative (nonclinical) tasks. |
| structured data entry | documentation using controlled vocabulary via preloaded data, drop-down menus, radio buttons, and sentence builders |
| superbill/encounter form | an itemized form used to document services provided to the patient and the diagnoses for the services; also the main source of information used to create the insurance claim |
| third-party payer | a party other than the patient, spouse, parent, or guardian who is responsible for paying all or part of the patient's medical costs, typically the insurance company. |
Created by:
maggiemaew