Outcome 6.3 — Electronic Health Records (EHR) and Coding for Dental Health Information Management

Electronic Health Record (EHR)

A digital version of a patient’s clinical chart designed to store information that is searchable, shareable, and traceable over time.

Structured Data

Data that is organized in a specific format like dropdowns and checkboxes, making it easier to report and audit.

Unstructured Data

Free-text narrative notes that capture clinical reasoning but are harder to analyze and report on.

Medical/Dental History Updates

Documenting new conditions, surgeries, and medications in a patient's record.

Chief Complaint

The primary reason a patient seeks healthcare, documented in the record.

Clinical Findings

Results from exams and measurements including periodontal and radiographic findings.

Assessment/Diagnosis

The evaluation of a patient's condition and the identification of the problem.

Progress Notes

Documentation of care provided to a patient during a specific visit.

Informed Consent

Documentation that a patient understood the treatment risks and benefits before proceeding.

Copy-Forward/Chart Cloning

A documentation error where old findings are carried forward without verification.

Locating and Retrieving Information

The process of efficiently finding data in a patient record to support clinical decisions.

Demographics Registration

Patient information including name, date of birth, and other identifiers.

Clinical Decision Support

Alerts and reminders embedded in EHRs to enhance clinical decision-making.

Quality Dimensions in HIM

Attributes like accuracy, completeness, consistency, validity, and security that maintain data quality.

Authenticity in Documentation

Ensuring that entries in a record are made by the identified author.

Timeliness

The requirement that data entries are made as close as possible to the time of care.

Role-Based Access Control (RBAC)

Security measure that limits access to EHRs based on user roles.

Minimum Necessary Access

The principle of accessing only the information necessary to perform a specific task.

Document Indexing

The process of attaching documents to the correct patient, date, and type within an EHR.

Scanning Protocol

The steps involved in converting paper documents into electronic format for EHRs.

Current Dental Terminology (CDT) codes

Codes used in dental settings to categorize procedures for billing and reporting.

Insurance Claim Forms

Structured documents used to submit claims for reimbursement from insurers.

Medical Terminology

Standardized vocabulary used to describe anatomy, conditions, procedures, and findings.

Consent Documentation

Records that indicate a patient has given permission for a specific treatment.

Auditing Tools

Mechanisms within EHRs that track who accessed and modified patient records.

Unique User Identification

A security practice that assigns individual logins to each user to track actions.

Quality Check in HIM

Verifying accuracy and completeness of documents after scanning or input.

Version Control

Managing different drafts of documents to ensure the final version is clearly identified.

Release of Information (ROI)

Providing patient records to authorized parties in accordance with legal and privacy standards.

Minimum Necessary Standard

The rule that requires disclosure of the least amount of information necessary for a task.