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Personal Health record

maintained and owned by the patient

Electronic Health Record

data from ALL sources that have treated an individual

Electronic Medical Records

computerized records of ONE physician's encounter with a patient over time

Institute of Medicine

defines EHR to function: Health info. and data, results, orders, decision support, electronic communications, patient support, administrative, reporting and population mgt.

total conversion

may be costly; allows all patient data to be converted at once while office still sees patients

incremental conversion

gradual change to EHR, lower cost, smoother transition and less impact on office, however paper is still used and not all patient data available

hybrid conversion

uses combination of paper and electronic forms of data

clinical templates

allow doctors to document patient encounters into EHR on structured form

clinical vocabularies

common definitions for medical terms that ease communication by decreasing ambiguity


clinical vocabulary designed to encompass ALL terms used in medicine (Systemized Nomenclature of Medicine Clinical Terms): also used for anatomy, nursing, diagnosis/ problem lists, content of lab results, units of measure & immunizations (CVX, MVX)


terms and codes used for electronic exchange of lab results & clinical observations (Logical Observation Identifiers Names & Codes)


thesaurus database of medical terms

ICD-9 and ICD-10

international classification of diseases developed by the World Health Orgnanization (WHO)


procedural code system

ICD-9 vs. ICD-10

(International Classifications of Diseases)
ICD-9 has 3-5 alphanumeric for inpatient and outpatients with 3-4 numeric procedure codes; ICD-10 has 3-7 alphanumeric for inpatient & outpatients with 7 alphanumeric procedure codes


current procedural terminology; maintained by the AMA (american medical assoc.) descriptive terms & codes for reporting medical services & procedures performed in an outpatient setting (evaluation, anesthesia, surgery, lab, medicine)


Healthcare Common Procedure Coding System: codes for products, supplies & services not included in CPT maintained by the Centers for Medicare/Medicaid Services (CMS)


Centers for Medicare/Medicaid Services


Health Level 7: messaging standards for scheduling, medical record/image mgt., pt. admin., observations, financial mgt., public health notification and pt. care; also for pt. demographics


National council for Prescription Drug Programs: for retail pharm. transactions


Institute of Electrical & Electronics Engineers: device to device connectivity


Digital Imaging & Communications in Medicine: gets image info to workstations


vaccines administered


manufacturers of vaccines


Center for Disease Control


National Immunization Program


Use Federal drug terminologies from FDA

Active ingredient

FDA established names & UNII codes (Unique Ingredient Identifier Codes)

Manufactured Dosage

FDA/CDER data standards manual

Drug product

FDA National Drug Codes (NDC)

Medication Package

FDA Standards manual

Label Section Headers

LOINC Clinical Structured Product Labeling (SPL)

Special Populations


Drug Classifications

Dept. of Veteran Affairs National Drug File Reference Terminology (NDF-RT)

Clinical Drug

National Library of Medicine's Rx Norm


Health Insurance Portability & Accountability Act
Title I: health insurance reform: rights for the transfer of elctronic healthcare data
Title II: administration & simplication standards put privacy and security in place to ensure confidential PHI

Patient chart includes:

Vital Signs, Chief Complaint, Progress Notes, Past Medical Hx, Family Hx, Social Hx, allergies, medications, HPI (hx of present illness), ROS (review of systems), Diagnosis & assessment, treatment plan


a feature of most EHR's-- Advantages: auto checks for drug interactions, safety checks, and will send alerts for potential Rx problems

Primary benefits of EHR

unlimited access to pt. info., decreased waiting for medication delivery and test results, increased efficiency & accuracy


Computerized Physician Order Entry: app to enter pt. care info and provides support tools which results in improved pt. & outcomes


electronic medication administration record & scheduling: to track meds going in and out of a pharmacy/hospital, etc. (helps with errors and ADE-adverse drug events)

5 rights of eMars

right patient, right medication, right dose, right time, right route

medication reconciliation

process of obtaining and updating an accurate list of all patient meds


personal health record: a patient's lifelong medical hx in electronic format (personal hx, allergies, immunizations, surgeries, etc.). This does NOT replace legal records of providers

Types of PHR

1. Computer based, stand alone: downloaded software transferred to a portable memory device in order to access from another location
2. Internet based, tethered: access provided by insurance co. or provider; limited editing ownership maitained by access organization
3. Internet based, untethered: web based app involving username/password, editing as needed
4. Internet based, networked/interoperable: networked between insurance, pharmacies, other healthcare organizations, continually updated--disadvantage: does not ensure complete privacy/security


companies that process health info and execute elctronic transactions


designated record set: group of info. that includes PHI and is maintained by a covered health entity


electronic protectected health information


Notice of Privacy Practices


these are conditions regarding treatment, payment and operations--conditions under which PHI can be released without consent


defined as: name, address, Names of relatives & employers, SS#, Ph and fax #, email address, Health plan id#, account #, fingerprints, website address, MR#, serial numbers of vehicles and photos


Health information technology

Unified Medical Language System

electronic resource containing various medical terms


range of motion: referring to patient joints--can be limited or full or even "no" which means a lack of movement in the joint alltogether

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