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EHR
Chapter 1 vocabulary
| Question | Answer |
|---|---|
| Audit | A review of employee activity within the EHR system, including an examination of which files were accessed or modified, when, & why. |
| Certification Commission for Healthcare Information Technology (CCHIT) | a recognized certification body for EHRs ande their networks. The CCHIT is an independent, voluntary , private sector initiative whose goal is to accelerate the adoption of health information technology. |
| 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. |
| CMS 1500 claim form | A standardized template that speeds claims processing for doctors and suppliers; also called a universal claim form. |
| 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 | The sum of money that is paid by the patient, usually at the time medical services are rendered. |
| Day sheet | A register for daily business transactions; also called a day journal. |
| Documentation | The process of recording data about a patient's health history and status, including clinical observations and progress notes, diagnoses of illnesses and injuries. |
| Electronic health record (EHR | A computerized patient health record that allows the electronic management of a patient's health information by multiple healthcare providers & stores the patient's contact information. |
| Electronic transcription | Data entry into the EHR using handwriting recognition, voice recognition, electronic sentence building, scanning, and other means. |
| Interoperability | The ability of separate EHR systems to share information in compatible formats. |
| Patient information form | A form used to gather data about the patient, including contact information, health history, current health status, and chief complaint. |
| Patient statement | A billing & scheduling document that lists copayments made by the patient,reimbursement received from the patient's insurance company, outstanding amount owed, and appointment details. |
| Practice management software | Software used in a medical office to accomplish administrative tasks, including entry of patient demographics, record-keeping for insurance & other billing transactions, appointment scheduling, & advanced accounting functions. |
| Practice Partner | A top-related, CCHIT-certified, intergrated system of EHR & practice management software published by McKession Corp. Practice Partner is used with this textbook ot illustrate the features and functionality of an EHR system. |
| 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. |
| Health informatin & dat management | The EHR's cardinal function is to be a central repository for the patient's health information from a variety of sources. |
| Results management | Instituting an EHR system should make test results easily accessible. |
| Order Management | The ability to order tests & prescribe medications electronically reduces errors & lower costs. |
| Decision support | The EH The EHR software should offer features that help clicians manage patient care according to evidence-based treatment guidelines. |
| Electronic communication & connectivity | The chief advantage of an EHR system is that it allows all providers & institutions involved in a patient's care to communicate & share data efficiently, thereby improving the quality of the patient's care. |
| Patient support | Many EHR systems have tools for paatient education, such as wound care instructions or guidelines for self-monitoring of blood glucose. |
| Administrative processes | Billing & scheduling can be handled electronically. |
| Reporting & population health | Diagnoses of infedtious diseases can be reported confidentially to public health authorities, and researchers can access EHR databases to gather epidemiologic statistics. |
Created by:
shagkitty