TERM #1 CH.1-5
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Created by:
SABYGALINDO on August 25, 2011
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46 terms
Terms | Definitions |
|---|---|
 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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