Chapter 1 - Electronic Health Record Key Terms (MA 171)

Encounter

A documented interaction or visit between a patient and healthcare provider.

copayment

A fixed sum of money that is paid by the patient, usually at the time medical services are rendered.

patient information form (PIF)

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

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.

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.

Certification Commission for Healthcare Information Technology (CCHIT)

A recognized certification body for EHR systems and their networks. The CCHIT is an independent, voluntary private-sector initiative whose goal is to accelerate the adoption of Health information technolgy.

Day sheet

A register for daily business transaction; 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.

Structured data entry

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

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, plans of care, patient education and self-care instructions give, vital signs taken, physical assessment findings, laboratory and imaging test results, medical treatments prescribed or administered, surgeries performed, and outcomes; the term can also refer to the chronologic record that results from such data entry.

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.

Computerized provider order entry (CPOE)

An EHR function that allows a physician or other prescriber to order medications and tests using an automated format; CPOE can reduce prescribing error, delays, and duplication and simplify inventory and billing processes.

account ledger

An accounting billing document that lists services provided, copayments made by the patient, reimbursement received from the patient's insurance company, and outstanding amount owed.

Electronic transcription

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

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 advance accounting functions.

interoperability

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

chief complaint (cc)

The patient's stated primary reason for seeking treatment.