medical records words

Question 1

Medical record

Answer 1

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

Question 2

Medical history

Answer 2

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)

Question 3

Medical encounter

Answer 3

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

Question 4

American Health Information Management Association (AHIMA)

Answer 4

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

Question 5

Personal health record

Answer 5

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

Question 6

Data quality management model

Answer 6

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

Question 7

Data quality characteristics

Answer 7

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

Question 8

History

Answer 8

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

Question 9

Exam

Answer 9

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

Question 10

Medical decision making

Answer 10

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

Question 11

Electronic health records (EHR)

Answer 11

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

Question 12

Hybrid health records

Answer 12

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

Question 13

Source-oriented medical record (SOMR)

Answer 13

A record that is organized by data source or subject

Question 14

Problem-oriented medical record (POMR)

Answer 14

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

Question 15

Clinical data repository (CDR)

Answer 15

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

Question 16

Electronic medical administration record (EMAR)

Answer 16

An EHR system for medication management that uses the CDR database

Question 17

Patient care charting system

Answer 17

A type of EHR that records progress notes and assessments

Question 18

Hospital information system (HIS)

Answer 18

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

Question 19

Certification Commission for Health Information Technology (CCHIT)

Answer 19

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

Question 20

Pay for performance (P4P)

Answer 20

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

Question 21

Centers for Medicare and Medicaid Services (CMS)

Answer 21

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

Question 22

Dental Office Reference Manual (DORM)

Answer 22

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

Question 23

Dental Periodicity Schedule

Answer 23

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

Question 24

Dental extraction

Answer 24

The removal of primary teeth

Question 25

Electronic prescribing

Answer 25

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

Question 26

Electronic data interchange (EDI)

Answer 26

The digital exchange of structured data between computer systems; reduces errors and can be used, for example, for sending prescriptions to a pharmacy.

Question 27

Intranet

Answer 27

A closed network of computers within a facility or organization

Question 28

Interoperability

Answer 28

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

Question 29

Health information exchange (HIE)

Answer 29

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

Question 30

Notice of privacy practices (NPP)

Answer 30

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.

Question 31

Regional Health Information Organization (RHIO)

Answer 31

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

Question 32

Health Insurance Portability and Accountability Act (HIPAA)

Answer 32

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

Question 33

Patient confidentiality

Answer 33

Protection from private healthcare information being released without prior permission

Question 34

Privacy rule

Answer 34

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

Question 35

Protected health information (PHI)

Answer 35

Any information about a person’s health, healthcare or payment for health services that can be linked to a specific patient compliance

Question 36

Traditional medical record

Answer 36

A medical chart stored and maintained in paper format