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A paper- or computer-based tool for collecting and storing information about the healthcare servcies provided to a patient in a single healthcare facility; also called a patient record, medical record, resident record, or client record, depending on the healthcare setting
The dates, numbers, images, symbols, letters, and words that represent basic facts and observations about people, processes, measurements, and conditions
Factual data that have been collected, combined, analyzed, interpreted, and/or converted into a form that can be used for a specific purpose
electronic health record
(EHR) An electronic record of health-related information on an individual that conforms to nationally recognized interoperability standards and that can be created, managed, and consulted by authorized clinicians and staff across more than one healthcare organization
personal health record
(PHR) An electronic record of health-related information on an individual that conforms to nationally recognized interoperability standards and that can be drawn from multiple sources while being managed and controlled by the individual
A specially trained typist who understands medical terminology and translates physicians' verbal dictation into written reports
allied health professional
A credentialed healthcare worker who is not a physician, nurse, psychologist, or pharmacist (for example, a physical therapist, dietitian, social worker, or occupational therapist)
A professional organization that establishes the standards against which healthcare organizations are measured and conducts periodic assessments of the performance of individual healthcare organizations
An insurance company (for example, Blue Cross/Blue Shield) or healthcare program (for example, Medicare) that reimburses healthcare providers (second party) and/or patients (first party) for the delivery of medical services
The healthcare worker responsible for assigning numeric or alphanumeric codes to diagnostic or procedural statements
Data extracted from individual health records and combined to form deidentified information about groups of patients that can be compared and analyzed
Numeric or alphanumeric characters used to classify and report diseases, conditions, and injuries
The numeric or alphanumeric characters used to classify and report the medical procedures and services performed for patients
quality improvement organizations
(QIO) An organization that performs medical peer review of Medicare and Medicaid claims, including review of validity of hospital diagnosis and procedure coding information; completeness, adequacy, and quality of care; and appropriateness of prospective payments for outlier cases and nonemergent use of the emergency room; until 2002, called peer review organization
utilization management organization
An organization that reviews the appropriateness of the care setting and resources used to treat a patient
Centers for Medicare and Medicaid Services
(CMS) The division of the Department of Health and Human Services that is responsible for developing healthcare policy in the United States and for administering the Medicare program and the federal portion of the Medicaid program; called the Health Care Financing Administration (HCFA) prior to 2001
data quality management
A managerial process that ensures the integrity (accuracy and completeness) of an organization's data during data collection, application, warehouseing, and analysis
Concept of data quality that involves whether the data is up-to-date and available within a useful time frame; See data currency
The level of detail at which the attributes and values of healthcare data are described
Th extent to which healthcare-related data are useful for the purpose for which they were collected
The quality or state of being hidden from, or undisturbed by, the observation or activities of other persons or freedom from unauthorized intrusion; in healthcare-related contexts, the right of a patient to control disclosure of personal information
A legal and ethical concept that establishes the healthcare provider's responsiblity for protecting health records and other personal and private information from unauthorized use or disclosure
The means to control access and protect information from accidental or intentional disclosure to unauthorized persons and from unauthorized alteration, destruction, or loss.
source-oriented health record format
A system of health record organization in which information is arranged according to the patient care department that provided the care
problem-oriented health record format
A health record documentation approach in which the physician defines each clinical problem individually
integrated health record format
A system of health record organization in which all the paper forms are arranged in strict chronological order and mixed with forms created by different departments
Results retrieval technology that permits viewing of data by type and manipulation of several different types of data; also referred to as results managment systems
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