Lesson 5: Electronic Health Records

Electronic medical records (EMR)

Contain a patient’s complete medical records in a digital format and are restricted to a singe facility

Data redundancy

Repeated inputs of identical info that occurs when multiple versions of the same data are stored

Electronic health records (EHR)

Patients’ health info in a digital format created and shared by providers across more than one health care setting

Inoperability

Ability of software to exchange and use info

Clinical workflow

A process involving a series of tasks performed by various people within and between work environments to deliver care

US Dept of Health and Human Services (HHS)

Organization that protects public health and provides human services

Unethical remarks

Refers to the lack of proper rules of conduct

Subpoena

A court order that summons a person to appear to testify for a trial

Meaningful use

The minimum US government standards for electronic health records

Centers for Medicare and Medicaid Services (CMS)

A federal agency under HHS to administer various health care programs of the nation

National Committee for Quality Assurance (NCQA)

A not-for-profit organization evaluating and reporting on the quality of the nation’s managed health care programs

Agency for Healthcare Research and Quality (AHRQ)

An HHS agency that finds evidence to make health care safer and more accessible and affordable

Problem-oriented medical record (POMR)

Standardizes the way providers organize and store patient info

SOAP format

Subjective, Objective, Assessment, Plan format

Progress notes

Detailed documentation of the patient’s encounters with the medical office

History and physical (H&P)

Provides up-to-date info about the patient’s medical history and the findings of their physical exam