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Medical Records
Med term medical records vocab
| Term | Definition |
|---|---|
| medical record | the lifetime record of a patient’s health, health problems, and medical care at a particular institution |
| medical history | a patient’s health history, including information such as allergies, medications being taken, past medical history (PMH, e.g., prior illnesses and surgeries), social history (SH, e.g., occupation and habits such as smoking, exercise, and alcohol use), and |
| medical encounter | a single patient-provider visit, during which the patient’s chief complaint (CC) and the history of the present illness (HPI) are discussed, a physical examination (PE) is performed, and a diagnosis (DX) and treatment (TX) plan are made |
| personal health record | a medical record that is maintained by the patient for personal benefit |
| American Health Information Management Association (AHIMA) | not-for-profit professional organization serving the educational, credentialing, networking, and advocacy needs of health information management (HIM) professionals |
| data quality management model | an AHIMA concept that standardizes data storage, maintenance, and organization according to ten quality characteristics |
| data quality characteristics | the ten AHIMA data quality characteristics that require data to be accurate, accessible, comprehensive, consistent, current, defined, granular, precise, relevant, and timely |
| history | refers to a patient's past medical history, as well as the history of the present illness |
| exam | includes both a physician's physical examination of a patient, as well as any test results |
| medical decision making | component of the health record that substantiates the care provided, supports reimbursement for each procedure, and serves as a legal document that validates the treatment provided for each diagnosis |
| electronic health records (EHRs) | health records that allow real-time communication, reporting, and record keeping through electronic transmission |
| hybrid health records | medical records that incorporate elements of paper-based records and electronic records |
| source-oriented medical record | a record that is organized by data source or subject |
| problem-oriented medical record | a record that organizes data by problem, and uses four categories: a database of all objective information, a numbered problem list, initial treatment plans, and progress notes |
| clinical data repository (CDR) | a special database that manages healthcare data from different sources such as labs, pharmacies, and radiology networks |
| electronic medication administration record (EMAR) | an EHR system for medication management that uses the CDR database |
| patient care charting system | a type of EHR that records progress notes and assessments |
| hospital information system (HIS) | a computerized management solution that handles all aspects of a hospital’s operations, including financial and medical operations |
| Certification Commission for Health Information Technology (CCHIT) | a nonprofit organization with the mission of accelerating the adoption of information technology (IT) in healthcare, it measures and certifies the effectiveness of EHR products based on predefined criteria |
| pay for performance (P4P) | performance-oriented incentives for hospitals and physicians to improve the quality of patient healthcare |
| Centers for Medicare and Medicaid Services (CMS) | a US government organization that oversees services for the federally sponsored Medicare and Medicaid insurance programs |
| Dental Office Reference Manual (DORM) | a reference manual that provides information about administrative policies relating to a dental practice |
| Dental Periodicity Schedule | a schedule that recommends certain oral health services for children according to age |
| dental extraction | the removal of primary teeth |
| electronic prescribing | the digital authoring, transmission, and filling of physician medication prescriptions, it is intended to reduce errors, time, and costs |
| electronic data interchange (EDI) | the digital exchange of structured data between computer systems; reduces errors and can be used, for example, for sending prescriptions to a pharmacy |
| intranet | a closed network of computers within a facility or organization |
| interoperability | the ability to share data between multiple systems without altering the meaning of the data |
| health information exchange (HIE) | the digital exchange of healthcare data between different organizations in order to improve patient care, and reduce costs and errors |
| notice of privacy practices (NPP) | a legally required notice that healthcare providers and plans must distribute to their patients that outlines how their protected health information is used and disclosed, and the rights the patient has |
| Regional Health Information Organization (RHIO) | a regional health information exchange that centralizes data from multiple facilities, including hospitals and clinics |
| Health Insurance Portability and Accountability Act (HIPAA) | legislation that provides guidelines on maintaining patient privacy and confidentiality through standardized methods of handling healthcare data |
| patient confidentiality | protection from private healthcare information being released without prior permission |
| privacy rule | a part of HIPAA that outlines standards for maintaining patient confidentiality and safeguarding financial and administrative data during electronic transfer |
| protected health information (PHI) | any information about a person’s health, healthcare, or payment for health services that can be linked to a specific patient compliance |
Created by:
Vaishnavi.
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