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Referral

Sending a patient to another doctor for special care.

Audit

A review or check of records to make sure everything is correct.

Matrix

A schedule layout showing available appointment times.

Encounter Form

A form used during a visit to list services and charges.

Electronic Health Records (EHR)

Digital records of a patient’s health that can be shared between clinics.

SOAP

A method to write medical notes that includes Subjective, Objective, Assessment, and Plan.

Dictation

Speaking medical notes out loud to be typed later.

Subjective

Information from the patient, like how they feel.

Real Time Adjudication (RTA)

Instant decision on an insurance claim.

Objective

Facts the doctor can measure or see, like temperature.

Progress Note

Notes about how a patient is doing over time.

Privacy Officer

Person who protects patient health information.

Medicare Promoting Interoperability (PI) Program

A program to help doctors share patient info safely and easily.

Indexing

Organizing files so they’re easy to find later.

Continuity of Care

Ongoing care without gaps or delays.

Encoder

Software that helps find medical billing codes.

Chronologic

In time order, from earliest to latest.

CHEDDAR

A method to write medical notes using Chief Complaint, History, Examination, Details, Drugs, Assessment, Return visit.

HL7 Protocols

Rules for sharing health info between computer systems.

Chief Complaint (C/C)

The main reason the patient came in.

Transcription

Typing up spoken medical notes.

Utilization

Using something, like a service or resource.

Flex Time

Flexible work hours that can change day to day.

Tickler File

A reminder system organized by date.

HPIP

A method to write medical notes that includes History, Physical exam, Impression, and Plan.