Intro to Electronic Health Records - Chapter 1

Account Ledger

List of services provided, payments made, reimbursements patient received from insurance company, adjustments, and outstanding money owed.

Audit

Review of employee activity, including examination of files accessed, modified, when, and why.

Clinical Decision Support (CDS)

Set of patient-centered tools embedded within the EHR software to improve patient safety and ensure care conforms to protocol.

Computerized Provider Order Entry (CPOE)

EHR function allowing providers to enter ordered medications and tests using an automated format, reducing errors and delays.

Continuity of Care (CoC)

Key aspect of quality that involves planning and coordination of care, communication among care team members, and accessibility of information.

Co-Payment (CoPay)

Fixed sum of money paid by the patient, dictated by the insurance company, usually at the time of medical service.

Day Sheet

Register of all daily business transactions such as patient services, payments, and adjustments.

Documentation

Process of recording data about a patient’s health information, including history, status, diagnoses, and treatment plans.

Electronic Health Record (EHR)

Digital record that allows management of patient health information by healthcare providers.

Electronic Medical Record (EMR)

Digital health record managed by authorized clinicians within a healthcare organization.

Electronic Transcription

Data entry into the EHR using handwriting recognition, electronic sentence building, and scanning.

Encounter

Documented interaction or visit between a patient and a healthcare provider.

HIPAA

Health Insurance Portability and Accountability Act of 1996, ensuring patient privacy and security.

Interoperability

Ability of separate EHR systems to share information in compatible formats.

Meaningful Use (MU)

Part of federal EHR Incentive Program providing financial incentives for effective EHR implementation.

Office of the National Coordinator for Health Information Technology (ONCHIT)

Division coordinating the implementation of health information technology.

Patient Information Form

Form used to gather data about the patient, including demographics and insurance information.

Practice Management Software (PMS)

Software used in medical offices for administrative tasks like billing and appointment scheduling.

Structured Data Entry

Documentation using controlled vocabulary and preloaded data options.

Superbill / Encounter Forms

Itemized form documenting services provided to the patient and diagnoses for insurance claims.

Third-party Payer

Entity other than the patient responsible for paying all or part of the patient’s medical costs, usually an insurance company.

Simchart for the Medical Office (SCMO)

Web-based EHR with functionality for physicians’ offices and outpatient facilities.

HIPAA 5010

Standard electronic format for claims processing.

American Recovery and Reinvestment Act (ARRA)

Legislation aimed at improving healthcare through technology.

Eligible Professionals (EPs)

Healthcare providers who can demonstrate meaningful use of EHRs to improve care quality and efficiency.

Who own the medical record?

Whoever made the record

HIPAA 5010

Standard electronic format that speeds claims processing for physicians and suppliers

SCMO

Simchart for the Medical Office

CEHRT

Certified Electronic Health Record Technology

eRx

Electronic Prescription

Doctrine of Professional Discretion

Doctrine that states providers can exercise best judgment when deciding whether to share progress notes and clinical observations with a patient who is being treated for mental or emotional disturbances

CMS

Centers for Medicare and Medicaid Services

MRN

Medical Record Number, automatically assigned to a patient

Diagnostic Imaging Utilization Act of 2013

Requires use of CDS tools when ordering diagnostic testing and added that providers who wish to receive MU incentive program funding must implement at least one CDS element for patients

Established Patient

A patient who has been seen in office within the last 3 years.

Claim Scrubber

Looks for missing data or data that doesn’t match and generates a report so that the missing information can be entered or information can be corrected

Is automated sentence building a means of electronic transcription?

No