TERM #1 CH.1-5

Created by SABYGALINDO 

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46 terms

EHR

most commonly accepted and used term for storing and accessing patient medical information electronically

CPR (computer base patient record)

contains all patient information for the patients lifetime and includes medical information from all specialties and fully interoperable

CCR(continuity of care record)

health provider oriented and defines a core se of data reflecting the most relevent and timely facts about a patient healthcare & is accessible and readable by other electronic systems

PHR(personal health record)

an internet based connection that allows the patient to become an interactive source of health information and health managment

ASP(application server provider)

the EHR is stored, maintained and updated off site by an EHR web hosting company for the doctor

POWER OUTAGE

a concern a provider may have about EHR

BETTER PATIENT CARE

a benefit of EHR

HEALTH MAINTENANCE ISSUES

tracked by patients age,gender,past diagnoses,past medical procedures, or even family medical history

TABLET PC

a portable means of entering information in an EHR utilizing the TAP&GO method

REMOTE ACCESS

enables the health care provider to wotk on the EHR from a nursing home,their home address or hospital

HL7

messeging standards by the CHI for health information

DICOM(digital imaging and communication in medicine)

standards from digital imaging communication in medicine from CHI

FUNCTIONALITY

abiliity to carry out specific tasks

INTEROPERABILITY

compability language with other software programs

HIT

health information technology

ACCESS AUTHORIZATION

appropiate access to minimum necessary information

HUGN

human gene nomenclature

ADMINISTRATIVE PROCESSES

schedueling, biling, medical claims, authorization, referrals...etc.

SNOMED-CT

standards for terms for laboratory result contents anotomy,diagnosis, problems and nursing

MEDICAL DECISION SUPPORT

information for drugs prescribing and dosing, disease screening, diagnosis and treatment, care quality improvement

REPID SELECT

a search function of springcharts that is activated once the user pauses after typing a few letters

MEASUREMENT OPTION

select what units of measurethe vitals will be recorded in imperial or numeric

DRUG FORMULARY

listings of pharmaceutical substances and formulas for making medicinal preparations

BI-DIRECTIONAL FLOW

data exchange to and from two different software programs

STANDARD SELECT

type in the necessary letters then click on the search icon to activate the search function

TIME STAMP

will automatically insert a 12hr. time or military 24hr. time at various locations in the program

PRACTICE VIEW SCREEN

the first screen displayed upon succesful logon

DOCTOR READY

an example of a patient status

TRACKER GROUP

clinics that have offices in more than one location will use this feature to track the patients separately at each location

CHECKOUT

logs the recorder checkout time for the patient

POPUP TEXT

a repository of text in springchart enabiling clinic staff rapid selection of predefined text

TOOLBAR

a lineup of icons that give the user shortcut access to the most commonly used functions of the programs

MESSAGE ARCHIVES

a sent or received message not regarding a patient will be saved here and can be reactivated

DEMOGRAPHICS

a patients personal statistical data such as name,address,birthday,and so on

CARE TREE

located on the right side of the patients chart it lists encounters (progress notes),tests and other records

CATEGORY PREFERENCES

this window enables the clinic administator to create predetermined customized lists of medical data

CHART ALERT

allows for the inclusion of important text that will appear in red above the encounters category on the charts care tree

ENCOUNTERS

a category in the care tree that stores many of the documents that are created from encounters with the patient

EXPORT CHART

enables you to export any portion of the chart as a text file

FACE SHEET

the portion of a patients chart that displays the patients demographics, medical history, and medical information

FMHX

family medical history record

IMAGING

test that include: x-rays, CT scans, MRI, and so on

PENDING TEST

once new lab, imaging,medical test have been ordered, they are sent to this area

PMHX

patients past medical history

ROUTINE MEDS

the patients routine medications and over the counter meds(OTC)

ELECTRONIC CHART

equivalent to a patients paper chart containing face sheet information and ongoing medical encounter documentation

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