NHA Electronic Health Records Module 1

CPOE

( Computerized Provider Order Entry) Use of computers system to enter and process prescriptions and treatments at the point of care.

eMAR

( Electronic Medication Administration Record) An electronic record containing a patient's prescribed medications, administration times, and who administered them.

HIE

( Health Information Exchange) Allows health care professionals and patients to appropriately access and securely share a patient's medical information electronically.

HIPAA

( Health Insurance Portability And Accountability Act) A federal law that regulates use of patient personal identifiable information.

LIS

( Laboratory Information System) Database of prescribed laboratory tests and results transferred from instruments used to analyze the test.

NPP

( Notice Of Privacy Practice) Document required by law to inform a patient how the organization will use their healthcare info.

PHR

( Personal Health Record) controlled by the patient

RIS

( Radiology Information System) transfer imaging orders and patient data to testing devices.

CPT

( current Procedural Terminology) A coding classification system is used to assign diagnosis and procedure codes.

ICD

( international Classification Of Diseases) International method of classifying disease, injury & cause of death for research.

DNR

(Do Not Resuscitate) instructs health care providers not to do CPR

eFax

(Electronic Fax) used to send & receive patient information. sent from the computer to the fax machine.

EHR

(Electronic Health Record) A record of patient medical and health care information accessible to providers and other staff members with login credentials regardless of location.

EMR

(Electronic Medical Record) Medical records maintained by a single provider.

HIM

(Health Information Management) practice of organizing, managing, and protecting health info data.

OCR

(Optical Character Recognition) The process that converts an image of text into a machine-readable text format.

PACS

(Picture, Archiving, and communication system) stores and transmit images and interpretation of studies.

PMS

(Practice Management Software) A system that stores info- On the revenue cycle process - appointments -registration -scheduling -coding -billing

Registration Form

A form that consists of administrative information about a patient, including personal, financial, legal, and some clinical data.

Advance Directives

A legal document that contains information about a patient's treatment choices when they are unable to make healthcare decisions.

Assignment of Benefits

A patient's authorization to allow health insurance payment to be made directly to the provider of service

Medical Record Number

A set of numbers is used to identify a patient and associated recorded health data.

hybrid System

A system that uses both paper and electronic-based processing for documentation of health information.

Interoperability

The ability of systems to share and then use information

Usability

The ease with which a person can interact with hardware and software to provide safe, efficient, and quality care.