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SIM CHART
ELECTRONIC HEALTH RECORD
| Question | Answer |
|---|---|
| Chapter 1 - Key terms Accounts Ledger | List of 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 cost. |
| Computerized provider order 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 reducing prescribing errors, delays and duplication. |
| Continuity of care | A key aspect of quality that encompasses planning and coordination of care, communication among members of healthcare team, and accessibility and transportability of info. |
| 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, including clinical observations, progress notes, diagnoses of illnesses and injuries, plans of care, patient education and self-care instructions given, vital signs taken, |
| Documentation, cont'd. | physical assessment findings, laboratory and imaging test results, medical treatments prescribed or administered, surgeries performed and outcomes; term can also refer to chronological record that results from such data entry. |
| Electronic Health Record (EHR) | Computerized patient health record that allows the electronic management of a patient's health information by multiple healthcare providers and stores the patient's contact information. Term can also refer to system that manages records. |
| Electronic transcription. | Data entry into the EHR using hand-writing 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 to separate EHR systems to share information in compatible format. |
| Office of the National Coordinator for Health Informatkiion Technology ONCHIT) | 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 including entry of patient demographics, record keeping for insurance and other billing transactions, appointment scheduling and advanced accounting features. |
| Superbill/encounter form | An itemized form used to document services provided to the patient and the diagnoses for the service. Also the main source of information used to create the insurance claim. |
| Structured data entry | Documentation using controlled vocabulary via preloaded data, drop-down menus, radio buttons and sentence builders. |
| 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. |
| Clinical Information includes | Medication list, allergies list, Immunization records, Lab reports, Pathology reports, surgical reports, H&P assessment findings, Risk assessment, Preventive services, progress note, vital signs and growth charts, Imaging test results. |
| Administrative information | Patient demographics, Emergency contact person, correspondence, referral and consultation letters, prior authorizations, Insurance information, billing account ledgers, superbills/encounter forms, day sheets, appt history, diagnosis and procedure codes. |
| Legal documents | Complete medical record considered a legal document. Contains DNR orders - may need to be accessed quickly so medical team knows how to proceed in an emergency, Medical records release, Consent forms, HIPAA forms, Advance directives - living will, |
| Legal documents continued | DNR, healthcare Power of Attorney and Disclosure logs. |
| Who owns the medical record? | Provider but patient controls the information within the medical record. Patient has legal right to access or view a copy of his or her medical information. |
| EHR Software | SimChart for the Medical Office (SCMO) is a web based EHR ttyhat has real functionality used in physician's offices and outpatient facilities while giving students a safe academic learning environment. |
| Chapter 2 - Key Terms Active patient | An established patient who has seen the provider oranother provider in the billing group within the past 3 years. |
| button | An element of the user interface on which the user can click to execute a command such as save, confirm, cancel or exit, |
| check box | A specialized type of button that toggles on (checked) and off . unchecked). Check boxes are often used when more than one response might be appropriate as in"Check all that apply" but sometimes they should be interpreted to mean yes or no |
| closed patient record | The record of a patient who will not be returning to the medical office or who has not been seen in the past 10 years. |
| Default | A preselected value orsetting that will be used unless the user specifies a substitute by overriding the preselected choice. |
| Field | Space allocated on a form forspecific numeric ortext data. |
| Inactive patient | An established patient who has not been seen for3 or more years. |
| Radio button | A specialized type of button on a software interface that toggles on (round button visible) andoff (blank circle). Radio buttons tellthe user that only response is appropriate because 2 radio buttons can't be depressed at the same timee |
| Retention period | The amount of time patient records must by law be maintained by the medical office. |
| Drop-down menu | A menu of further choices that appears when a word on the menu bar is clicked. SCMO functions have a drop down menu. |
| Chapter 3 - Key Terms Anonymity | The patient's right to have private health data collected in a way that can never be linked or traced back to him or her. |
| Audit trail | A record that traces a user's electronic footsteps by recording activity and transactions, including unsuccessful attempts to view unauthorized screens within the EHR system. |
| Authentication | The process of determining whether the person attempting to access a given network or EHR system is authorized to do so. User authentication can include password entry or use of biometric data (such as fingerprint or voice signature) or a |
| Authentication (cont'd) | smart card (a data laden microchip). |
| Authorization | A document giving a covered entity permission to use protected health information for specified purposes other than treatment, payment, or healthcare operations or to disclose protected health information to a third party specified by the patient. |
| Business associates | A person or entity that perform certain functions or activities that involve the use or disclosure of protected health information on behalf of a covered entity. |
| Confidentiality | The obligation of professionals to keep a patient's information in confidence. The patient's right and expectation that individually identifiable health information will be kept private and not disclosed without the patient's permission. |
| Confidentiality (cont'd) | Confidentiality is protected by law to varying degrees. |
| Consent | Permission given to a covered entity for uses and disclosures of protected health information for treatment, payment and healthcare operations. |
| Consumer reporting agency | An agency regulated by the Federal Trade Commission (FTC) under Fair Credit Reporting Act (FCRA) that sells or cooperatively exchanges consumer credit information and history. |
| Covered entities | Healthcare providers, health plans, and healthcare clearinghouses that transmit health information electronically. |
| Disclosure | Giving access to, releasing, or transferring information to a person or entity. |
| Ethics | Rules and standards of conduct that govern professional behavior and arise from our shared understanding of morality. |
| Laws | Formal enforceable rules and policies based on community standards of conduct. |
| Minimum necessary standard | A key provision of the HIIPAA Privacy Rule requiring that covered entities limit unnecessary or inappropriate access to and disclosure of protected health information. |
| Minimum necessary standard (cont'd) | Disclosures should include only the minimum necessary amount of information to accomplish a given purpose. |
| Off-label indication | A use for a prescription drug other than that for which the US Food and Drug Administration (FDA) has approved it. |
| Password | A sequence of characters and sometimes spaces used to prevent unauthorized access to or disclosure of patient information contained in secure electronic files. |
| Privacy | The patient's freedom to determine when, how much and under what circumstances his or her medical information may be disclosed. |
| Protected Health Information (PHI) | Individually identifiable health information (for example demographic information, billing information, medical record numbers, account numbers, physical or mental condition, etc. that is stored, maintained, or transmitted electronically. |
| Safeguards | Measures taken to prevent interference with computer network operations and to avert security breaches involving the unauthorized use, disclosure, modification, erasure or destruction of PHI. |
| Safeguards (cont'd) | These measures are specified by HIPAA Security Rule which appli |
| Screen Saver | A program that displays animation or images on the screen if input (such as a keystroke) is not received for a given time period. |
| Secondary Use | A use of health information that is not directly related to patient care. Such uses include statistical analysis, research, quality and safety assurance processes, public health monitoring, |
| Secondary Use (Contd) | payment, provider certification or accreditation and marketing and other business activities. |
| Chapter 4 - Key Terms - Administrative Use of the Electronic Health Record | |
| Double booking | Giving 2 or more patients the same appointment slot with the same provider. |
| Encryption technology | A system that keeps data secure by converting them to an unreadable code during transmission and then encrypting the information when it reaches the recipient. |
| Fax machine | A device capable of encoding documents and sending them over a telephone line, a secure fax sends fax transmissions via secure email, eliminating many of a fax's security risks. |
| No-show | |
| Patient flow | The efficient movement of patients through the medical office as a product of accurately estimated patient volume, a consistent provider pace and efficient scheduling practices. The term generally refers to the overall flow of patients but can refer to |
| Patient flow (cont'd) | the path of an individual patient. |
| Patient portal | A secure website where a patient can access personal health information, schedule appointments, and refill prescriptions 24 hours a day using a username and password. Oftentimes it is part of a provider's electronic health record system. (EHR). |
| Purging | The process of separating inactive patient health records from the active ones. |
| Secure Electronic Messaging | A component of a patient portal or personal health record that allows for secure communication between the patient and the provider. |
| Secure E-mail | An email system capable of transmitting an encrypted message and storing it in a coded format until it is retrieved by the recipient via a secure web link. |
| Show rate | The percentage of patients in a practice who arrive for appointments as scheduled or call in advance to cancel or reschedule. |
| Telephone etiquette | A polite helpful response and respectful manner toward callers that show patients they are cared for and valued. |
| Template | An electronic document that has a basic format in which the required information can be entered. Templates are often created for those documents that are needed over and over again such as a new patient welcome letter. |
| Views | Different ways of displaying the same or similar information on a computer screen, usually with an increasing or decreasing level of detail (looking at an electronic calendar in daily, weekly and monthly views) |
| CHAPTER 5 - Key terms Clinical use of the electronic Health Record | |
| Acute condition | An illness or injury that is episodic (eg a seizure), has a sudden onset (such as a broken bone), is of limited duration (eg bronchitis and generally responds well to prompt medical attention. |
| Anthropometric measurement | Measurement of height, weight and size used to compare the relative proportions of the human body in health and illness. |
| Chief Complaint (CC) | A brief statement of the problem, condition or symptoms that prompted the patient to seek medical care. sometimes referred to as Chief Concern. |
| Chronic condition | An illness that persists for a prolonged time (typically 3 months or longer), such as diabetes mellitus, emphysema and arthritis. |
| E-visit | An evaluation and management service provided by a physician or qualified health professional to an established patient using a web based or similar electronic-based communication network |
| E-visit (cont'd) | for a single patient encounter that occurs over safe, secure online communication systems. |
| High-alert medication | A medication that poses a heightened risk of injury or death when administered improperly. |
| History of Present Illness (HPI) | Details about the duration, time, location, severity, context, associated signs and symptoms, quality, and modifying factors related to the patient's illness. |
| Medication Reconciliation | The process of comparing the medication list in the patient's EHR with the patient's self-report of the medications he or she has been taking. |
| Objective | Readily seen, perceived, or measured by the clinician, not only by the patient. |
| PFSH | Past (medical), family and social history. |
| Review of Systems (ROS) | An organized inventory of each organ system, completed as part of the initial patient interview to pinpoint any unusual findings in the patient's history. |
| Speech Recognition | A technology that converts speech into text. |
| Subjective | Perceived only by the patient and not evident to or measurable by the clinician. |
| Chapter 6 Key Terms - Using the Electronic Record for Reimbursement | |
| Abstracting | Collecting data from a health record. Used for determining CPT, HCPS or ICD-10-CM codes and for release of information. |
| Abuse | Unintentional deception in which a provider inappropriately bills for services that are not medically necessary, do not meet current standards of care, or are not medically sound. |
| Coding Variance | Medical coding mistakes caused by computer error or by various kinds of human error, from simple carelessness to incorrect application of coding guidelines and procedures. |
| Compliance plan | A written set of office policies and procedures intended to ensure compliance with laws regulating billing, coding, and third-party reimbursement. |
| CPT (Current Procedural Terminology). | A comprehensive set of medical codes that describe procedures,, treatments, and services for financial reimbursement and analytical purposes. |
| Electronic Data Interchange (EDI). | The standardized format used to transfer data from one computer system to another. |
| Eligibility | Entitled to receive benefits from a health plan. |
| Encounter Form | A form generated to reflect the services and charges for a patient visit. It includes patient information and account balance. This may also be referred to as a Superbill. |
| Fraud | Presenting claims for services that an individual or entity knows or should know to be false, resulting in a benefit to the presenting party. |
| Guarantor | The person who is legally responsible for a patient's account; the guarantor is usually the patient, but the guarantor for a minor or a person of decreased mental capacity may be a parent, trustee or legal guardian. |
| HIPAA 5010 | The standard electronic claim format used by a non-institutional provider or supplier to submit a claim electronically to Medicare and most other insurance carriers for covered services. |
| ICD-10-CM | International Classification of Diseases, Tenth Revision, with Clinical Modification. A coding system used to describe inpatient and outpatient diagnoses. |
| Medical coding | The process of assigning standard numeric or alphanumeric codes to diagnoses, procedures, and treatments for research, disease tracking and reimbursement purposes. |
| Medical Identity Theft | The unauthorized use of someone else's personal information to obtain medical services or to submit fraudulent medical insurance claims for for reimbursement. |
| Pay for Performance | (P4P). An outcomes-based payment model that offers providers financial incentives for meeting specific standards and electronically documenting compliance with them; punitive measures may be applied to providers who fail to comply. |
Created by:
bterrelonge