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Chapter 7
| Term | Definition |
|---|---|
| Medica Record | a collection of data recorded when a patient seeks medical treatment |
| Electronic medical records (EMR) | a digital version of the paper charts in the clinician’s office |
| Electronic health record (EHR) | built to share information with other health care providers, such as laboratories, specialists, and hospitals so that the patients’ total health information is in one record |
| Patient Identification Information: | Name, address, phone numbers, e-mail address, marital status, copy of driver’s license, and workplace contact information (if appropriate). Emergency contact information, along with person responsible for payment, as well as their contact information |
| Insurance information: | For patients with private insurance, a copy of current insurance card that contains policy number and information for the insurance company should be included |
| The Health Information Technology for Economic and clinical health (HITECH) Act of 2009, part of ARRA | established programs to improve health care quality, safety, and efficiency through the promotion of health information technology (HIT), including EHRs and private and secure electronic health information. |
| Consent forms | These may include a consent to treat, a consent to disclose Protected Health Information (PHI) and/or a consent for a special procedure |
| Clinical data | This is all information related to the patient’s condition, the course of treatment, and progress |
| Other administrative information: | Treatment refusal and information about patient dismissal if appropriate. |
| Five Cs of documentation | Concise, Complete (and objective), Clear, Correct, Chronologically ordered |
| PHOTOGRAPHS, VIDEOS, AND OTHER METHODS OF PATIENT IMAGING | In today’s health care environment, it has become increasingly common to record patients’ images through the use of photography, video recording digital imaging, and other visual recordings |
| Correction | a change in the information that is meant to clarify inaccuracies found after the document is complete |
| Addendum | new documentation used to add information to the original entry |
| Amendment | is used to clarify or correct information in the electronic health record. |
| Chart | used to travel within one health care facility—that is, from storage to exam room, to X-ray or lab, to the sonogram room—carried by a physician, nurse, or other health care practitioner who was charged with keeping the record secure |
| Insurance claims | The medical office supplies specific requested information but does not usually send the patient’s entire medical record |
| Another Physician | The physician may photocopy and send all records or may send a summary |
| Courts | When a subpoena duces tecum is issued for certain records (the subpoena commands a witness to appear in court and to bring certain medical records), the patient’s written consent to release the records is waived |
| stage 1 of meaningful use | 2010–2013) focused on the adoption by providers of certified EHRs |
| Stage 2 attestation began in 2014 | This stage focuses on interoperability and health information exchange |
| Stage 3 of meaningful use | is a continuation of improving patient access. Providers will set a single set of objectives and measures that they agree to meet. |
| Sharing of information online | is a valuable resource for both patients and providers |
| Telemedicine | the exchange of medical services and information using electronic communication |
| Primary care | Primary care physicians or other allied health professionals provide a consultation with a patient |
| Remote patient monitoring | Often referred to as home telehealth, this service uses devices to remotely collect and send data to a home health agency or a remote diagnostic testing facility for interpretation |
| Consumer medical and health information | Organizations providing telemedicine may support specialized health information and online discussion groups to provide peer-to-peer support |
| Medical education | Targeting health care professionals in remote areas, telemedicine providers offer continuing medical education and special medical education seminars |
Created by:
Julieni Abasi