INTRODUCTION ACMA TEST VERIFIED 100% CORRECT!!
Key Terminology for Electronic Record Keeping
Electronic Medical Records (EMR) are computerized records of one physician's encounter with a patient over time. The EMR reflects treatment of a patient by one physician.
Electronic Health Record (EHR)...
INTRODUCTION ACMA TEST VERIFIED 100%
CORRECT!!
Key Terminology for Electronic Record Keeping
Electronic Medical Records (EMR) are computerized records of one physician's
encounter with a patient over time. The EMR reflects treatment of a patient by one
physician.
Electronic Health Record (EHR) reflects the data from all sources that have
treated the individual.
Personal Health Record (PHR) are maintained and owned by the patient. The
patient makes the decision whether to share the contents with their physician.
Acute care, most often refers to a hospital, treats patients with urgent problems
that cannot be handled.
Ambulatory care refers to treatment without admission to hospital.
Clinical templates allow doctors to document patient encounters into an EHR on
a structured form.
RADT refers to registration, admissions, discharge and transfer
UPI is the unique patient identifier links all clinical observations, tests,
procedures, complaints, evaluations, and diagnoses to the patient.
DATA may be structured or unstructured. Unstructured data could be a dictated
report, a written progress note, or voice files et.al. Structured data is standard
templates, bar codes and numeric codes et. al.
Decision support software is used to access current information about a disease
or condition. Used by physicians.
Voice Recognition software translates what a provider is saying and types those
words into text.
Master Patient (person) Index (MPI) is where patients are listed/entered only once
and allows for documentation of each visit.
Button an element of the user interface on which the user can click to execute a
command such as confirm, cancel or exit
Clinical templates allow doctors to document patient encounters into an EHR on
a structured form.
Context Specific generated to help the user in a specific context or to carry out a
particular task
RADT refers to registration, admissions, discharge and transfer
Retention the length of time records are stored by a medical office
Status Code indicates a patient's behavior or current status
Type of Visit Code codes that identify common types of patient visits, specify
their typical duration and identify special instructions to handling each kind of
visit
UPI is the unique patient identifier links all clinical observations, tests,
procedures, complaints, evaluations, and diagnoses to the patient.
HIPAA Security Rules
HIPAA requires the usage of password protection on all electronic devices used
to access patient information. If you work in a reception area that is visible to
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