Electronic Health & Medical Records

Flashcards covering key vocabulary and concepts related to Electronic Health Records (EHR) based on the lecture notes.

Electronic Health Record (EHR)

Eliminates duplication of forms, simplifies reviewing information, and decreases medical errors.

Conditioning

Grouping related papers together, removing paper clips and staples, and fixing damaged records in paper filing systems.

Releasing

Marking a form to be filed, indicating it is ready to be filed, often with a provider’s initials or stamp.

Indexing and Coding

Determining where to place the file in the record within a paper filing system.

Sorting

Ordering papers in specific groups within a paper filing system before filing.

Electronic Medical Record (EMR)

Digital charts to be used within a single facility.

Personal Health Record (PHR)

Access controlled solely by the patient; data is entered by the patient; files are owned by the individual.

History of Present Illness (HPI)

Chief complaint; detailed account of the patient's current medical issue.

Meaningful Use

Guidelines to improve quality, safety, efficiency, and reduce health disparities through the use of certified EHR technology.

Release of Information (ROI) Form

Also known as the “HIPAA” form; allows a practice to share patient information with authorized parties.