Ehrgo Health Information Terminology Flashcards
(45 cards)
Abstracting
The process of extracting information from a document to create a brief summary of a patient’s illness, treatment and outcome.
Addendum
Note that is added (and attached to) to a completed note after it has been finalized (signed by the author).
Authorization
The granting of permission to disclose confidential information. As defined in terms of the HIPAA privacy rule, an individual’s written permission to use or disclose his or her personally identifiable health information for purposes other than treatment, payment or health care operations. (45 C.F.R. § 164.508)
Care plan
A standardized written plan for the patient’s care for the health care team to follow.
Centers for Medicare & Medicaid Services (CMS
The federal agency within the United States Department of Health and Human Services (HHS) that administers the Medicare, Medicaid, Children’s Health Insurance Program, and the Health Insurance Marketplace. (CMS)
Clinical data
Captured during the process of diagnosis and treatment, supports direct patient care and is used for health care reimbursement, planning and research purposes. (Abdelhak)
Coded data
Controlled data entered into specific fields in the EHR which enable the retrieval, or data mining, of the entered information. Examples of coded data include ICD diagnostic codes, CPT procedural codes and health factors.
Current Procedural Terminology (CPT
): A coding system used to provide uniform language that accurately describes medical, surgical and diagnostic services.
Data mining
Aggregating and reporting of data from coded fields within the EHR.
Diagnosis
The name for the health problem that you have. Often called a “medical problem” or just simply, “problem.”
Diagnosis code
A code describing the principal diagnosis, additional conditions that coexisted at the time of admission, or developed subsequently, and which had an effect on the treatment received or the length of stay. Sometimes referred to as the ICD-10 code.
Diagnosis Related Groups (DRG)
A classification system that groups patients according to diagnosis, type of treatment, age and other relevant criteria. Under the prospective payment system, hospitals are paid a set fee for treating patients in a single DRG category, regardless of the actual cost of care for the individual. (CMS)
Electronic Health Record (EHR)
Longitudinal patient records that are maintained electronically in a manner that is accessible to caregiver, the patient and others who need access to specific information or to aggregate information to prevent illness and improve future treatment
Electronic Medical Record (EMR)
Electronic patient records that are developed by individual health care providers/organizations. EMRs are composed of whole files as opposed to individual data elements. The data from the EMR are the source of data for the electronic health record. (Abdelhak)
Encoder
Specialty software used to facilitate the assignment of diagnostic and procedural codes according to the rules of the coding system.
Healthcare Provider
A person who is trained and licensed to give health care. Also, a place that is licensed to give health care. Doctors, nurses, and hospitals are examples of health care providers. (Fordney)
Health Factor
A type of coded data that captures patient health information for which no standard diagnostic code exists, such as Family History of Alcohol Abuse, Lifetime Non-smoker, No Risk Factors for Hepatitis C, etc
Health Informatics (aka: Healthcare Informatics)
): The intersection of information science, medicine, and health care. It deals with the resources, devices, and methods required to optimize the acquisition, storage, retrieval, and use of information in health and biomedicine. (MTU) Health informatics tools include not only computers, but also clinical guidelines, formal medical terminologies, and information and communication systems.
Health Information Technology
Broadly defined as the use of information and communication technology in health care.
Health Insurance Portability and Accountability Act (HIPAA):
A US law that provides patients with access to their medical records and provides privacy standards to protect patients’ medical records and other health information. (MedicineNet)
Inpatient
Health care you receive when you are admitted to a hospital.
International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM)
The official system used in the United States prior to 2014 to classify and assign codes to health conditions and related information. The use of standardized codes improves consistency among physicians in recording patient symptoms and diagnoses.
International Classification of Diseases, Tenth Revision (ICD-10)
Was created in 1992 as the successor to the previous ICD-9 system. In the United States, an official use of the ICD-10 system began in 2014. It is split into two systems: ICD-10-CM (clinical modification) for diagnostic coding and ICD-10-PCS (procedure coding system) for inpatient hospital procedure coding.
Meaningful Use
Meaningful use describes the use of health information technology (HIT) that leads to improvements in healthcare and furthers the goals of information exchange among health care professionals. To become Meaningful Users, health professionals need to demonstrate they’re using certified EHR technology in ways that can be measured in quantity and in quality, such as the recording and tracking of key patient health factors to enable the planning and delivery of timely and effective care. (HealthIT.gov)
