Medical Records

medical record

the lifetime record of a patient’s health, health problems, and medical care at a particular institution

medical history

a patient’s health history, including information such as allergies, medications being taken, past medical history (PMH, e.g., prior illnesses and surgeries), social history (SH, e.g., occupation and habits such as smoking, exercise, and alcohol use), and family history (FH)

medical encounter

a single patient-provider visit, during which the patient’s chief complaint (CC) and the history of the present illness (HPI) are discussed, a physical examination (PE) is performed, and a diagnosis (DX) and treatment (TX) plan are made

personal health record

a medical record that is maintained by the patient for personal benefitpersonal health record

American Health Information Management Association (AHIMA)

not-for-profit professional organization serving the educational, credentialing, networking, and advocacy needs of health information management (HIM) professionals

data quality management model

an AHIMA concept that standardizes data storage, maintenance, and organization according to ten quality characteristics

data quality characteristics

the ten AHIMA data quality characteristics that require data to be accurate, accessible, comprehensive, consistent, current, defined, granular, precise, relevant, and timely

history

refers to a patient's past medical history, as well as the history of the present illness

exam

includes both a physician's physical examination of a patient, as well as any test results

medical decision making

component of the health record that substantiates the care provided, supports reimbursement for each procedure, and serves as a legal document that validates the treatment provided for each diagnosis

electronic health records (EHRs)

health records that allow real-time communication, reporting, and record keeping through electronic transmission

hybrid health records

medical records that incorporate elements of paper-based records and electronic records

source-oriented medical record

a record that is organized by data source or subject

problem-oriented medical record

a record that organizes data by problem, and uses four categories: a database of all objective information, a numbered problem list, initial treatment plans, and progress notes

clinical data repository (CDR)

a special database that manages healthcare data from different sources such as labs, pharmacies, and radiology networks

electronic medication administration record (EMAR)

an EHR system for medication management that uses the CDR database

patient care charting system

a type of EHR that records progress notes and assessments

hospital information system (HIS)

a computerized management solution that handles all aspects of a hospital’s operations, including financial and medical operations

Certification Commission for Health Information Technology (CCHIT)

a nonprofit organization with the mission of accelerating the adoption of information technology (IT) in healthcare, it measures and certifies the effectiveness of EHR products based on predefined criteria

pay for performance (P4P)

performance-oriented incentives for hospitals and physicians to improve the quality of patient healthcare

Centers for Medicare and Medicaid Services (CMS)

a US government organization that oversees services for the federally sponsored Medicare and Medicaid insurance programs

Dental Office Reference Manual (DORM)

a reference manual that provides information about administrative policies relating to a dental practice

Dental Periodicity Schedule

a schedule that recommends certain oral health services for children according to age

dental extraction

the removal of primary teeth

electronic prescribing

the digital authoring, transmission, and filling of physician medication prescriptions, it is intended to reduce errors, time, and costs

electronic data interchange (EDI)

the digital exchange of structured data between computer systems; reduces errors and can be used, for example, for sending prescriptions to a pharmacy

intranet

a closed network of computers within a facility or organization

interoperability

the ability to share data between multiple systems without altering the meaning of the data

health information exchange (HIE)

the digital exchange of healthcare data between different organizations in order to improve patient care, and reduce costs and errors

notice of privacy practices (NPP)

a legally required notice that healthcare providers and plans must distribute to their patients that outlines how their protected health information is used and disclosed, and the rights the patient has

Regional Health Information Organization (RHIO)

a regional health information exchange that centralizes data from multiple facilities, including hospitals and clinics

Health Insurance Portability and Accountability Act (HIPAA)

legislation that provides guidelines on maintaining patient privacy and confidentiality through standardized methods of handling healthcare data

patient confidentiality

protection from private healthcare information being released without prior permission

privacy rule

a part of HIPAA that outlines standards for maintaining patient confidentiality and safeguarding financial and administrative data during electronic transfer

protected health information (PHI)

any information about a person’s health, healthcare, or payment for health services that can be linked to a specific patient compliance