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Flashcards in medical records words Deck (36):
1

Medical record

The lifetime record of a patient's health, health problems, and medical care at a particular institution

2

Medical history

A patient's health history, including information such as allergies, medications being taken, past medical history (PMH), social history (SH; occupation and habits such as smoking, exercise, and alcohol use), and family history (PH)

3

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 plan (TX) are formed

4

American Health Information Management Association (AHIMA)

Non-profit professional organization serving the educational, credentialing, networking, and advocacy needs of the health information management (HIM) professionals

5

Personal health record

A medical record that is maintained by the patient for personal benefit

6

Data quality management model

An AHIMA concept that standardizes data storage, maintenance, and organization according to 10 quality characteristics

7

Data quality characteristics

The 10 AHIMA data quality characteristics that require data to be accurate, accessible, comprehensive, consistent, current, defined, granular, precise, relevant, and timely

8

History

Refers to a patient's past medical history, as well as the history of the present illness

9

Exam

Includes both a physician's physical examination of a patient, as well as any test results

10

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

11

Electronic health records (EHR)

Health records that allow real-time communication, reporting, and record keeping through electronic transmission

12

Hybrid health records

Medical records that incorporate elements of paper-based records and electronic records

13

Source-oriented medical record (SOMR)

A record that is organized by data source or subject

14

Problem-oriented medical record (POMR)

A medical record that organizes data by problem, and uses 4 categories: a database of all objective information, a numbered problem list, initial treatment plan, and progress notes

15

Clinical data repository (CDR)

A special database that manages healthcare data from different sources such as labs, pharmacies, and radiology networks

16

Electronic medical administration record (EMAR)

An EHR system for medication management that uses the CDR database

17

Patient care charting system

A type of EHR that records progress notes and assessments

18

Hospital information system (HIS)

A computerized management solution that handles all aspects of a hospital's operations, including financial and medical operations

19

Certification Commission for Health Information Technology (CCHIT)

And non-profit 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

20

Pay for performance (P4P)

Performance oriented incentives for hospitals and physicians to improve the quality of patient healthcare

21

Centers for Medicare and Medicaid Services (CMS)

A US government organization that oversees services for the federally sponsored Medicare and Medicaid insurance programs

22

Dental Office Reference Manual (DORM)

A reference manual that provides information about administrative policies relating to a dental practice

23

Dental Periodicity Schedule

A schedule that recommends a certain oral health services for children according to age

24

Dental extraction

The removal of primary teeth

25

Electronic prescribing

The digital authoring, transmission and filing of physician medication prescriptions. This is intended to reduce errors, time and costs.

26

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.

27

Intranet

A closed network of computers within a facility or organization

28

Interoperability

The ability to share data between multiple systems without altering the meaning of the data

29

Health information exchange (HIE)

The digital exchange of healthcare data between different organizations, in order to improve patient care and reduce costs and errors

30

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, as well as the rights the patient has.

31

Regional Health Information Organization (RHIO)

A regional health information exchange that centralizes data from multiple facilities, including hospitals and clinics.

32

Health Insurance Portability and Accountability Act (HIPAA)

Legislation that provides guidelines on maintaining patient privacy and confidentiality through standardized methods of handling healthcare data.

33

Patient confidentiality

Protection from private healthcare information being released without prior permission

34

Privacy rule

A part of HIPAA that outlines standards for maintaining patient confidentiality and safeguarding financial and administrative data during electronic transfer.

35

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

36

Traditional medical record

A medical chart stored and maintained in paper format