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Ch. 1 Health Records
Med Office Procedures - Electronic Health Records
| Term | Definition |
|---|---|
| Account Ledger | List of services provided, payments made by the patient, reimbursement rcvd from patient's insurance company, adjustments, and outstanding amount owed. |
| Audit | Review of employee activity within the EHR (electronic health records) 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 the care conforms to published protocol for specific conditions, and reduce duplicate or unnecessary care and its associated costs. |
| 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 order medications and tests using an automated format; CPOE can reduce prescribing errors, delays, and duplication |
| Continuity of care | 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 | Register for all daily business transactions such as patient services, payments, and adjustments; also called a day journal. |
| Documentation | Process of recording data about a patient's health history and status, clinical observations, progress notes, diagnoses of illness and injuries, plans of care, pt education and self-care instructions given, vital signs, etc |
| Electronic health record (EHR) | EHR that allows for the management of a pt's health info by multiple healthcare providers and stores the pt's contact info, legal documents, demographic data, and admin info, term can be refer more broadly to a system that manages such records. |
| Electronic medical record (EMR) | EHR that allows management of a pt's health info by auth clinicians and staff members within a single healthcare organization. An EMR is an electronic version of a paper record. |
| Electronic transcription | Data entry into the EHR using handwriting recognition, voice recognition, electronic sentence building, scanning, and other means. |
| Encounter | Documented interaction or visit between a pt and healthcare provider. |
| Interoperability | 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 of health information. |
| Patient information form | Form used to gather data about the patient, including basic demographic info, medical insurance data, and emergency contact. |
| practice management software (PMS) | Software used in a medical office to accomplish administrative (nonclinical) tasks, including entry of pt's demographics, record-keeping for insurance and other billing transactions, appointment scheduling and advanced accounting functions. |
| Structured data entry | documentation using controlled vocabulary via preloaded data, drop-down menus, radio buttons, and sentence builders. |
| superbill/ encounter form | 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 | party other than the patient, spouse, parent, or guardian who is responsible for paying all or part of the pt's medical costs, typically the insurance company |
Created by:
chaisenpai
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