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HIT Chapters 2-4 Definitions

Health record

Principal repository for data and information about the healthcare services provided to an individual patient. who, what, when, where, & why


Represents basic facts about people, processes, measurements, conditons, etc. (facts)


After data has been collected and analyzed and converted into a form that can be used for a specific purpose (meaning)

Personal health record (PHR)

health record initiated & maintained by an individual

healthcare reimbursement

Based on the documentation contained in the health record

Quality improvement organizations (QIO) & utilization management organizations

evaluate the adequacy & appropriateness of the care provided by healthcare organizations

Centers for Medicare & Medicaid (CMS)

responsible for administering the ferderal MC program and federal portion of MA program. Used to be called HCFA-health care financing administration until 2001.

Data applications

the purposes for which data are collected

Data collection

the processes by which data are collected

Data warehousing

The processes & systems by which data are archived (saved for future use)

Data analysis

Process by which data are translated into information that can be used for designated application

Data quality management


Data accuracy

Means data are correct. Should represent what was intended or definied by the original source of the data

Data accessibility

Means that the data are easily obtainable

Data comprehensiveness

means that all required data elements are included in the health record

Data consistency

Means that the data are reliable

Data currency/timeliness

Means that healthcare data should be up-to-date & recorded at or near the time of the event or observation

Data definition

Means that the data & information documented in the health record are defined

Data granularity

Requires that the attributes & values of data be definied at the correct level of detail for the intended use of the data

Data precision

Term used to describe expected data values

Data relevancy

Means that the data in the health record are useful


Right of individual to control access to their personal health information


Refers to the expectation that the personal information shared by an individual with a healthcare professional during the course of care will be used only for its intended purpose


The protection of the privacy of individuals & the confidentiality of health records


Refers to the capacity of health record systems to provide communicaton linkages & allow the exchange of health record data among information systems

Health record format

refers to the organizations of electronic information or paper forms within the individual record

Source-oriented health record format

format that organizes the information according to the patient care department that provided the care (used in most acute care hospitals)

Problem-oriented health record format

Format that is a documentation approach in which the physician definies each clinical problems individually. organized into 4 components: database, problem list, initial plans, & progress notes

Integrated health record format

Format that organized all the paper forms in strict chronological order & mixes the forms created by different departments

Health record

Represents the main communicatoin mechanism used by healthcare providers. Tool for documenting patient care

Clinical data

documents the patient's medical condition, diagnosis, & procedures performes as well as the healthcare treatment provided

Administrative data

included demographic & financial as well as various consents & authorizations related to the provision of care & the handling of confidential patient information

Conditions of participation/coverage

Standards that are applied to facilities that choose to participate in MC and MA

Registration record

Documents demographic information about the patient

Medical history

Documents the patient's curent & past health status

Physical examination

Contains the provider's findings based on exam of the patient

clinical observation

Provides a chronological summary of the patient's illness & treatment as documented by physicans, nurses, and all allied healthcare professionals

Physician's orders

Document the physician's instructions to other parties involved in providing the patient's care including orders for medications and diagnostic/therapeutic procedures

Reports of diagnostic & therapeutic procedures

Describes the procedures performed and give the names of providers, includes findings of x-ray, mammograms, ultrasounds, scans, lab tests, & other diagnostic procedures

Consultation reports

Document opinions about a patient;s condition furnished by providers other than the attending physician

Discharge summary

concisely summarizes the patient's stay in the hospital

patient instructions

Document the instructions for follow-up care that the provider gives to the patient or patient's caregiver

Consents, authorizations, & acknowledgements

Documents the patient's agreement to undergo treatment or services, permission to release confidentialy information, or recognition that information has been received

Provisional diagnosis

Admitting or working diagnosis identified by the condition or illness for which the patient needs medical care

Chief complaint

Nature & duration of the symptoms that caused the patient to seek medical attention as stated in his/her own words

Present illness

Detailed chronological description of the development of the patient's illness, from the appearance of the first sympton to the present situation

Past medical history

Summary of childhood & adult illness & conditions, such as infectious diseases, allergies & drug sensitivities, accidents, operations, hospitalizations, & current medications

Social & personal history

marital status, dietary, sleep, & exercise patterns, use of tobacco, coffee, alcohol, & other drugs, occupation, home environment, daily routine, etc.

Family medical history

Diseases among relatives in which heredity or contact might play a role

Review of systems

Systemic inventory designed to uncover current or past subjective symptoms

Progress notes

Purpose is to create a chronological report of the patient's condition & response to treatment during their hospital stay and serve to justify further acute care treatment in the facility

Care plan

Summary of the patient's problems from the healthcare professional's perscpective for a specific patient admission & discharge documenting the patient's condition at regular intervals throughout the hospital stay

Implied consent

Is consent assumed by the patient voluntarily submitting to treatment

Expressed consent

consent that is either spoken or written

Anesthesia report

includes any preoperative medication & response to it, the anesthesia administered with dose & method of administration, the duration of administration, patient's vital signs under anesthesia, & any additional products given to the patient during the procedure

operative report

report that describes the surgical procedures performed on the patient

recovery room report

Report that includes the postanesthesia note, nurses notes regarding the patient's conditon & surgical site, vital signs, IV fluids, and other medical monitoring

Pathology report

Report dictated by pathologist after exam of tissue received for evaluation includes description of tissue from a macroscopic level & representative cells at microscopic level along with interpretive findings

Consultation report

Report documenting the clinical opinion of a physician based on his/her exam of patient at the request of attending physician

discharge summary

Concise account of the patient's illness, course, of treatment, response to treatment, & conditon at time of discharge. includes instructions for followup care

Transfer record/referral form

Report that includes a brief review of patients acute stay along with current status, discharge, & transfer order & additional orders sent to the facility patient being transferred to.

Autopsy report

Report that contains a description of the exam of a patients body after death


The study of the statistical characteristic of human population


Permission granted by the patient or patient's representative to release information


Term used when the permission is for treatment, payment, or healthcare operations

authorization to disclose information

Term used to allow the healthcare facility to verbally disclose or send health information to other organizations

Advance directive

Written document that that names the patient's choice of legal representative for healthcare purposes. the person is then empowered to make healthcare decison on behalf of the patient in the event the patient is not capable of expressing his/her preferences

patient self-determination Act (PSDA)

Requires healthcare facilities to provide written information on the patients rights to execute advance directives & to accept or refuse medical treatment. went into effect in 1991.

Resident assessement instrument (RAI)

Based on minimum data ses for long-term care includes the MDS, triggers, utilization guidelines, & resident assessment protocols.

Outcomes & Assessment information set (OASIS)

Foundation for the plan of care. MC uses this to determine payment

Basic principles of health record documentation

principles address the uniformity, accuracy, completeness, legibility, authenticity, timeliness, frequency, & format of health record entries

Deemed status

Status obtained after facilities receive accreditation from agencies such as Joint Commission

Det Norske Veritas (DNV)

International accreditating organization

Integrated health record

health record is arranged so that documentation from various sources is intermingled in strict chronological order

Personal health record

An electronic record of health-related information on an individual that conforms to nationally recognized interoperabiity standards & that can be drawn from multiple sources while being managed, shared, & controlled by the individual

Qualified EHR

Includes patient demographic & clinical health information such as medical history & problem lists, & has capacity to provide clinical decision support, support physician order entry, capture & query information relevant to healthcare quality, & exchange electronic health information with & integrate such information form other sources

Computer-based patient record (CPR)

A system specifically designed to support users thru availability of complete & accurate data, practitioner reminders & alerts, clinical decision support, links to bodies of medical knowledge, & other aids

Electronic medical record

An electronic record of health-related information on an individual that can be created, gathered, managed, & consulted by authorized clinicians & staff within ONE healthcare organization

Electronic health record

An electronic record of health-related information on an individual that conforms to nationally interoperability standards & that can be created, managed, & consulted by authorized clinicians & staff across MORE THAN ONE healthcare organization

evidence-based medicine

The practice of medicine that utilizes guidance-based information gleaned from research studies


special application to provide secure access to a specific application such as a physicians office to a hospital


special software that aids formatting of data for transmission among systems with a hospital, lab, or other providers. special program where specific data are identified as needing to be exchanged & then rules about how those data are structured are applied.

Discrete data/structured data

Consists of data elements that are raw facts or figures that can be processed by the computer such as lab values

Textual data

physicians describe patient conditions in narrative form

Computer output to laser disk (COLD) also referred to as electronic document/content management ED/CM systems

Systems that capture print images of lab results & other documents that are in a stand-alone electronic systems & make them available for viewing on a computer monitor

Electronic signature authentication (ESA)

System that require the author to sign into the system using a user ID & password, reivew the document to be signed, & indicate approval.

Clinical data repository (CDR)

A special kind of database that manages data from different source systems in the hospital or other provider settings, including direct entry of discrete data by the clinician.


Ensure that the appropriate data are collected & guide users in adhering to professional practice standards

Practice guidelines

Recommendation based on what experts believe should be done

Evidence-based guidance

Drawn from scientific research & clinical trials

Electronic medication administration record systems (EMAR)

An application that identifies when a drug is administered & aids in documenting the administration

Barcode medication administration record (BC-MAR)

Five rights of patients: right patient, right, drug, right time, right dose, & right route

Health information portability & accountability act (HIPAA) 1996

Encouraging the development of health information systems thru the establishment of standards & requirements for electronic transmission of certain health information.

identity matching algorithm

algorithm uses sophisticated probability equations to identify patients

Record locator service (RLS)

Process that seeks information about where a patient may have a health record available to the organization

national health information infrastructure (NHII)

Set of technologies, standards, applications, systems, values, & laws that support all facets of provider healthcare, individual health, & public health

natiinwide health information network (NGIN)

provide the technology to support national health information infrastructure. goal establish privately financed consortium to ensure public policy goals are execute & rapid adoption of interoperability is applied.

Meaningful use

Ability to demonstrate quality improvements thru use of EHR


Refers to the use of standard protocols to enable 2 different computers to share data with each other

Pay for performance (p4P) or pay for quality (P4Q)

Insurance company incentives to providers to reward data collections & in reporting clinical outcomes


Collection of specific data form a predefined data set which are used to dvelop reports across multiple patients

Integrated or tethered Personal health record

Generally integrated with an existing EHR in a hospital or clinic system

Automated personal health records

Health plans started offering these PHR that are largely controlled by provider or health plan with limited data entry directly by the patient

stand-alone or untethered personal health records

may be paper or automated often acquired thru a commercial vendor ususally thru a Web site


organized collection of data

Relational database

stores data in predefined tables that contain rows & columns similar to spreadsheet

Database management system (DBMS)

Software that organize, provide access to, & otherwise manage a database

Clinical data warehouse (CDW)

Form of database that are optomized to perform analysis on date on many different things at one time. used to analyze a large set of clinical data

data exchange standards/ message format standards/ interoperability standards

makes sure the interface is written correctly & the exchange of data occurs reliably


Defined ways to do something


helps exchange clinical images such as x-rays, CT, scans, etc.

National Council for prescription drug programs (NCPDP)

Enable the communicaiton of retail pharmacy eligibility inquiries & claims and exchange of prescriptions from physicians office

American national standard institute (ANSI) Accredited Standards committee X12 (ASC X12)

Provides standards for hospital, professional, & dental claims, eligibility inquiries, electronic remittance advice, & other standards

ASTM international

E31 Committee on health information has developed guidelines primary for various EHR management processes

Data comparability

Terms must have same meaning from one clinical system to another


Term used to describe fact that value of the data in the message has standardized meaning. message format standard specifies vocabulary which data is encoded

Standard vocabulary

Developed thru a process that confirms consensus on meaning of the term included in the vocabulary

SNOMED International

most comprehensive effort to standardize vocabulary for representation of medical knowledge, incorporates microglossaries that address nursing & other ancillary terminology


Refers to the set of all terms that may be used in a language


Grouping of the terms into various categories such as diseases of respiratory system

logical observation identifies, names & codes (LOINC)

provides names & codes for lab test results & other observations


Provides description of medications in clinical form

Universal medical device nomenclature system (UMDNS)

Provides standard terminology for medical devices

National drug codes (NDC)

used to maintain inventories of drugs in pharmacies or links to CPT in physicians offices

enterprise report management ((ERM)

Captures data from print files & other report-formatted digital documents such as emails

results retrieval

may be basic lookup where a query is made to access certain data from specific system such as lab results

Results management sytem

results retrieval technology couples with CDR permits not only viewing of data by type but also manipulation of several different types of data such as plotting lab results on graph against medication administered, vital signs, etc.

Human-computer interface

Technologies that make data capture easier for ex. point & click, drop down menus, etc

Discrete data

Entry thru point & click fields, drop-down menus, structured templates, or macros. make data entry & processing easier.

Speech & handwriting recognition

Can be very effective in certain situations when data entry is fairly repetitive & vocabulary used is fairly limited

Natural language processing (NLP)

Takes narrative text & converts to structured data


Refers to the configuration, structure, & relationships of all components of computer system

Client/server architechture

uses combination of computers to capture & process data.

Web services architecture (WSA)

utilizes web-based tools to permit communicaiton among different software applications

Local area networks (LAN)

Using hardware cable transmit data securely at very high speeds thru out a building, campus, or small geographic area

Wireless local are network (WLAN)

utilize radio waves or microwaces to transmit data without cable. ex. is bluetooth that beams data using infrared light. IrDA ports must be in close proximity. RFID similar to barcode scanning but can be done greater distance.

Wide area network (WAN)

Data are transmitted across wide geographic areas general depend on high density trunk lines such as T-1 or T-3

Wireless wide area network (WWAN)

Mobile communications cellular network technologies such as 3G


is called a protocol that aids data transmission by establishing standards for indicating the start & end of a message, by performing error checking to ensure data are transmitting correctly


one of most popular LAN protocols.

TCP/IP transmission control protocol/internet protocol

most healthcare organization use this to simplify their networking and to take advantage of web-based technology


A LAN that uses TCP/IP

Redundant array of independent disks (RAID)

inexpensive disks used as a storage media

Server redundancy

accomplished thru mirrored processes means that data set are entered & processed by 1 server, they are entered, & processed simultaneously by a second server

audit logs

is element of retention schedule

Best of fit

when most systems are from one vendor

dual core

vendor strategy where one vendor supplies the financial & administrative applications & another vendor supplies the clinical applications

Best of breed

a system was selected for each application & is considered to be the best in its class


When the care delivery organization already has a fair amount of automation but is not satisfied with level of functionality is more clinically oriented applications that would comprise the EHR

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