EHR (NHA)
statistic
A fact or piece of data. For example, collecting the number of patients with a positive tobacco screening
data point
A fact or unit of information from the health record
quality measures
A set of actionable tools to improve patient outcomes
The Joint Commission (TJC)
Accredits and certifies health care organizations to promote elf and effective care
legal data
Advanced directives, consents for care and procedures, notice of patient rights and privacy practices, and authorizations for release of records
revenue cycle
All the administrative and clinical tasks that contribute to the billing and collection process
covered entity
Any medical or health care service, organization, agency, or individual that has protected health information
claim
Billing form created by encounter data, used for reimburesement of services rendered
practice management software
Coordinates the business aspects of a practice
CPT
Current Procedural Technology
public interest disclosures
Data on vaccines, communicable diseases, dangers to the public, law enforcement, and worker's compensation activities
patient responsibility
Deductible, coinsurance, and copayment
durable medical equipment
Devices and supplies like canes and walkers, portable oxygenation systems, and continence supplies
DNR
Do Not Resuscitate
eFAX
Electronic Fax
EHR
Electronic Health Record
EMR
Electronic Medical Record
eMAR
Electronic Medication Administration Record
real-time documentation
Entering documentation into the EHR as it occurs
Centers for Medicare and Medicaid
Federal agency that administers Medicare and works cooperatively with state programs and Medicaid
HIE
Health Information Exchange
HIM
Health Information Management
ICD
International Classification of Diseases
clinical data
Laboratory and reports, allergies, medications, medical and surgical history, hospital records, and progress notes
Security Rule
Measures that should be taken to prevent improper use or disclosure of protected health information
incidental disclosures
Minor disclosures that can occur during legitimate use of information
OCR
Optical Character Recognition
financial data
Patient insurance coverage, employment information, payment plans, and records for costs not covered by insurance
consent
Permission for an organization to perform treatment and care for a patient
PHR
Personal Health Record
PACS
Picture Archiving and Communication System
PMS
Practice Management Software
Rx
Prescription
HIPAA
Privacy and security regulations
RIS
Radiology Information System
portal
Secure website for patients to access their health information
patient portal
Secure, online, 24-hour access to personal health information
HITECH Act
Security breach notifications (include business associates)
kiosk
Self-service patient check-in
preventive care screening
Tests performed to evaluate health status with the goal of keeping the patient healthy
staffing
The ability to understand the type and amount of staff required
cash flow
The amount of money generated by billing
public health
The health of the population, when considered as a whole
revenue cycle
The life of a claim, from creation to payment
supply chain
The network of suppliers or resources for an organization
coding
Translating the medical record (diagnoses, services, supplies) into standardized codes
ICD-10-PCS Codes
Used by inpatient hospitals
CPT Codes
Used by outpatient and professional organizations
Privacy Rule
What kind of information should be protected and how protected information can be used
narrow networks
When an insurer works with a small pool of in-network providers
