MED 130 Chapters 12 & 14 Study Guide: Electronic Health Records & Telephone Techniques

Comprehensive vocabulary review flashcards covering Chapter 12 (Electronic Health Records) and Chapter 14 (Telephone Techniques) based on course lecture notes and practice quizzes.

Paper chart

A physical folder containing a person's healthcare information; it can be lost, misfiled, damaged, or difficult to read.

Electronic medical record (EMR)

A digital chart mainly maintained inside one practice or healthcare organization.

Electronic health record (EHR)

A digital chart designed to share information among authorized healthcare organizations.

Personal health record (PHR)

Health information maintained and controlled by the individual receiving care; it may be stored online.

NAHIT

The National Alliance for Health Information Technology; the group associated with course definitions of the three record types.

Interoperability

The ability of different technology systems to exchange and make use of information.

Legibility

How easily written or typed information can be read.

Medical communication error

Incorrect, missing, unreadable, or misplaced information that can lead to unsafe decisions.

Patient identifiers

At least two pieces of information, such as full name and date of birth, used to confirm the correct person.

SX

A shorthand abbreviation for what a person feels or experiences, such as nausea or headache (symptoms).

Meaningful Use

Using certified digital-record technology in measurable ways that improve the quality, safety, and coordination of care rather than simply owning software.

Stage 1 (Meaningful Use)

The early phase focused on capturing health details electronically, including encounters, diagnoses, medication orders, and immunizations.

Stage 2 (Meaningful Use)

The phase that stressed sending and receiving clinical information electronically and advancing care processes.

Stage 3 (Meaningful Use)

The later phase that emphasized improving health outcomes and using information to enhance care.

HITECH Act

The 2009 federal law that promoted adoption of digital records and incentive programs for their meaningful use.

Implementation costs

Expenses for software, hardware, technical support, training, upgrades, and setup, identified in lecture as the biggest concern during adoption.

Required fields

Boxes on a computer screen that must be completed to finish an entry or save data.

Addendum

A dated, attributable note that corrects or adds to a finalized entry without erasing the original.

Audit trail

A system record that can show whose account accessed or changed a chart and when.

Minimum necessary access

Giving workers only the health information they need to perform their assigned duties.

HIPAA

A federal legal framework that protects patient health information and requires privacy and security safeguards.

Electronic scheduler

A tool for booking, moving, canceling, finding, and confirming appointments that may also send reminders.

Tickler file

A reminder list for tasks that need future attention or follow-up.

Coding mismatch flag

A warning that a charge and diagnosis may not support each other and need review.

Report generator

A software feature that summarizes stored data, such as revenues for common procedures.

Aging report

A financial listing of balances grouped by how long they have been unpaid.

Ancillary integration

A direct electronic connection for laboratory and diagnostic orders and results.

Patient portal

A secure online entry point for individuals to view permitted records, communicate, and use selected services.

Medication compatibility alert

A system warning indicating that a possible allergy or drug interaction needs prescriber review.

Professional greeting

A calm telephone opening that names the practice, identifies the employee, and offers help.

Second or third ring

The ideal point by which office staff should answer a routine incoming call.

Tone

The attitude a caller hears in the voice, such as warmth, patience, or irritation.

Enunciation

Forming words distinctly so someone on the phone can understand them.

Telephone etiquette

Respectful habits used when answering, listening, holding, transferring, and ending calls.

Answering service

An outside company that receives calls, especially after business hours, and follows approved instructions.

Automated voice response unit

A recorded menu that answers calls and routes them by caller selection, such as 'press 1.'

Completeness

The communication standard where all essential details are included so the receiver does not have to guess.

Clarity

The communication standard where wording is easy to read and understand without confusion.

Conciseness

A short, direct message format that still preserves all important details.

Courtesy

Showing kind, respectful, and considerate language and behavior even when someone is upset.

Cohesiveness

Arranging ideas and information in a connected, logical order.

Screening

Finding out who is calling, why they called, and enough details to direct the request properly.

Routing

Passing a caller or message to the person or department responsible for handling it.

Telephone triage

Determining urgency and the needed clinical response under an approved protocol or process.

Scope of practice

The duties that an employee is trained and legally authorized to perform under applicable rules.

Telephone message pad

A designated paper form kept close to the telephone for writing details while someone speaks.

Callback verification

Repeating the phone number to make sure the return call reaches the correct person.

Telehealth

Providing healthcare when individuals are in separate physical locations using audio, video, or other technology.

Store-and-forward

Sharing recorded clinical material securely for review at a later time rather than during a live call.

Remote patient monitoring

Collecting health measures at home for later review by an authorized care team.

Mobile health (mHealth)

Using phones or portable devices for health reminders, information, or home monitoring.