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EHR Exam 2 Terminology
Electronic Health Record
36
Health Care
Undergraduate 1
10/21/2009

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Term
Examination Protocol
Definition
beginning with the chief complaint, a standard set of examinationsteps that will specifically eliminate, or specifically confirm, potential underlying causes for the chief complaint
Term
Point of Care
Definition
the time at which treatment is being provided
Term
Templates
Definition
preformatted data collection screens containing specific structured and/or free-text data fields and designed to support efficient and complete documentation
Term
Free-Text Narrative
Definition
unstructured documentation that allows a practitioner to dictate or key text
Term
Graphic Displays
Definition
a format for presenting numerical data that has been entered into structured (coded) data fields,showing trends in clinical data and allowing comparisons over time
Term
Growth Chart
Definition
graphic display of the height and weight of pediatric patients comparing their data to a development standard for the patient's age group
Term
Daily Task List
Definition
designation of work that needs to be completed during scheduled hours by an employee of a practice
Term
Treatment  Plan
Definition
a final component of an assessment which specifies any number and variety of actions needed to appropriately address the patient's health care problem(s). In a SOAP note it is the content in the "P" section of the documentation
Term
Direct Faxing
Definition
transfer of health care provider information from one organization to nothe via facsimile transmission
Term
Electronic Data Interchange (EDI)
Definition
transfer of health care provider information from one organization to another electronically
Term
Order Details
Definition
specific items that must be entered by a health care provider to make an order complete
Term
Order Templates
Definition
the format of structured data entry items required to complete a medical order
Term
Procedure Notes Template
Definition
structured format documentation by a health carw provider describing the patient encounter
Term
Results Reporting
Definition
communications of the findings associated with a completed diagnostic test order
Term
Drug Vocabularies
Definition
national terminologies associated with pharmacy information systems to support accurate communication of prescriptiopns and assure correct drug labeling
Term
Medication (drug) Reference Information
Definition
published texts that provide details on drugs approved for use in the United States; often available in hardcopy or via software
Term
Order Format and Details(order sentence)
Definition
general sequence for the detailed information passed from prescribing provider to the pharmacy
Term
Medication (drug) Alerts and Reminders
Definition
messages sent to a health care provider that call attention to any potential adverse effects that ould result if the intended medication order is carried out
Term
Health Maintenance Reminder
Definition
a reminder given to a health care provider and/or a patient by the provider, calling attwntion to maintaining the patient's health status
Term
Telephone (voice mail) Patient Messages
Definition
messages recorded by voice over the telephone when the person or practice called cannot or does not answer the call
Term
E-Mail and Electronic Text Messages
Definition
scripted messages entered on one computer, cell phone, or PDA and then sent to another computer or receiving device
Term
Patient Portal
Definition
secure internet connection to a practice for communicationand access to practice databases by patient's
Term
Explanation of Benefits(EOB) or Remittance Advice (RA)
Definition
communication from a third-party payer to a practice indicating payment for services, claim problems for follow-up action, or non-coverage of services
Term
Code Sets
Definition
coding systems; a term particularly used for those approved by HIPAA regulations for use in electronic transactions
Term
Healthcare Common Procedure Coding Systems (HCPCS)
Definition
coding system designated by HIPAA for electronic transactions relating to procedures performed in the ambulatory setting
Term
Classification Setting
Definition
a system that groups similar diagnoses or procedures together for reporting purposes
Term
Cooperating Parties
Definition
represenatives from four organizations that together make reccomendations for ICD-9-Cm code modifications and additions
Term
Encoder
Definition
software with current coding classification systems embedded to assist with the coding process
Term
Encounter Form
Definition
preprinted paper template designed to record the diagnoses and procedures completed during an office visit along with their ICD and/or CPT codes
Term
Mapping
Definition
the linking of content from one terminology or classification system to another
Term
Nomenclature
Definition
a listing of coding terms
Term
Computer Assisting Coding (CAC)
Definition
use of coding software that automatically generates medical codes based on documentation in the patient record
Term
Natural Language Processing
Definition
software that applies artificial intelleigence to narrative text in order to extract terms and data
Term
National Provider Identifier (NPI)
Definition
a national identifying number assigned to a health care provider to use with HIPAA transactions, including medical billing
Term
Scrubber
Definition
software developed to review claims for discrepancies or errors and to validate complance with regulatory mandated prior to submision to third-party payers
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