Chapter 1 Intro to Electronic Health Records

Electronic Health Record EHR

A computerized patient health record that allows the electronic management of a patient's health information by multiple healthcare providers and stores the patient's contact information, legal documents, demographic data, and administrative information; the term can also refer more broadly to a system that manages such records.

Encounter

A documented interaction or visit between a patient and healthcare provider

Patient Information Form

A form used to gather data about the patient, including basic demographic information, medical insurance data, and emergency contact.

Third-Party Payer

A party other than the patient, spouse, parent, or guardian who is responsible for paying all or part of the patient's medical costs, typically the insurance company.

Superbill/Encounter Form

An itemized form used to document services provided to the patient and the diagnosis for the services. Also the main source of information used to create the insurance claim.

Electronic Transcription

Data entry into the EHR using hand writing recognition, voice recognition, electronic sentence building, scanning, and other means

Office of the National Coordinator for Health Informations Technology (ONCHT)

Division of the Office of the Secretary, within the Department of Health and Human Services. Coordinates the effort to implement health information technology ad the electronic exchange of health information.

Structured Data Entry

Documentation using controlled vocabulary via preloaded data, drop-down menus, radio buttons, and sentence builders.

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.

Practice Management Software (PMS)

Software used in a medical office to accomplish administrative (nonclinical) tasks, including entry of patient demographics, record-keeping for insurance and other billing transactions, appointment scheduling, and advanced accounting functions.

Interoperability

The ability of separate EHR system to share information in compatible formats.

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.

Continuity of Care

a key aspect of quality that encompasses planning and coordination of care, communication among members of the healthcare team, and accessibility and transportability of information.

Day Sheet

a register for all daily business transaction such as patient services, payments, adjustments; also called a day journal.

Audit

a review of employee activity within the EHR system, including an examination of which files were accessed or modified, when, and why.

Clinical Decision Support (CDS)

a set of patient-centered tools embedded within EHR software that can be used to improve patient safety, ensure that 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 ordered medications and tests using an automated format; CPOE can reduce prescribing errors, delays, and duplication and can simplify inventory and billing process

Account Ledger

lists services provided, payments made by payments made by the patient, reimbursement received from the patient's insurance company, adjustments, and outstanding amount owed.

Chief Complaint

the patient's stated primary reason for seeking treatment.

Documentation

the process of recording data about a patient's health history and status, including clinical observations and progress notes, diagnoses of illnesses and injuries, plan of care, patient educations and self-care instructions given, vital signs taken, physical assessment findings, laboratory and imaging test results, medical treatments prescribed and administered, surgeries performed and outcomes; the term can also refer to the chronologic record that results from such data entry