Vocab Terms
Electronic health record (EHR)
an electronic version of a patients medical record that can be shared between healthcare organizations; this includes information such as medical history, diagnoses, treatment plans, medications, immunization records, vital signs measurements, and imaging, test, and lab results.
demographic information
name, birthdate, address, and contact numbers
personal health record (PHR)
electronic collection of a patients health history and medical information.
Name three things a patient may be able to do using a patient portal.
Review information about their healthcare, medications, and tests.
Centers for Medicare and Medicaid services (CMS)
a federal agency within the US Department of Health and Human Services that is responsible for Medicare and Medicaid, among many other responsibilities.
HIPAA
Health Insurance Portability and Accountability Act, protects patients health information.
computerized provider order entry (CPOE)
a health information technology system that allows providers to electronically enter medication, lab, and radiology orders.
Meaningful Use
standards established by CMS to create incentives for the use of electronic health records (EHR)
paper charts
traditional method of keeping patient medical records.
requisition
detailing what tests are to be performed
Source-oriented medical records (SOMR)
a method of organizing paper medical records according to source category.
HITECH Act
encourages the use of PHRs (personal health record) to provide a more complete picture of the patient health history.
superbill
lists diagnosis codes, treatment provided or procedures performed, and codes associated with treatment.
Problem-Oriented medical record
A method of organizing paper medical records according to the patents problems and diagnoses.
what is the difference between EMR (electronic medical records) and EHR (electronic health records)
EMR is a system that can only be accessed by a single healthcare facility. EHR can be shared between healthcare organizations.
magnetic degaussing
Electronic records are treated with an erasing procedure.