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Medical Terminology: Medical Records & Documentation Part 4

Healthcare15 CardsCreated 2 months ago

This deck covers key concepts and definitions related to medical records and documentation, focusing on electronic systems and data security.

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Define: Electronic Health Record (EHR)

A digital version of a patient's paper chart that contains comprehensive health information and is shared among healthcare providers. The clinic transitioned to an Electronic Health Record (EHR) system for better patient management.
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Key Terms

Term
Definition
Define: Electronic Health Record (EHR)
A digital version of a patient's paper chart that contains comprehensive health information and is shared among healthcare providers. The clinic trans...
Define: Electronic Medical Record (EMR)
A digital record of a patient's health information that is created and maintained by one healthcare provider. The doctor accessed the Electronic Medic...
Define: Interoperability
The ability of different healthcare information systems and software applications to communicate and exchange data effectively. Interoperability betwe...
Define: Clinical Decision Support (CDS)
Tools and systems that provide healthcare providers with knowledge and patient-specific information to enhance decision-making. The Clinical Decision ...
Define: Patient Portal
An online platform that allows patients to access their health information, communicate with healthcare providers, and manage appointments. The patien...
Define: Health Information Exchange (HIE)
The electronic sharing of health information among different healthcare organizations to improve the quality of care. The Health Information Exchange ...
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Medical Terminology: Medical Records & Documentation Part 4
TermDefinition
Define: Electronic Health Record (EHR)
A digital version of a patient's paper chart that contains comprehensive health information and is shared among healthcare providers. The clinic transitioned to an Electronic Health Record (EHR) system for better patient management.
Define: Electronic Medical Record (EMR)
A digital record of a patient's health information that is created and maintained by one healthcare provider. The doctor accessed the Electronic Medical Record (EMR) to review the patient's treatment history.
Define: Interoperability
The ability of different healthcare information systems and software applications to communicate and exchange data effectively. Interoperability between systems allows for seamless patient data sharing among providers.
Define: Clinical Decision Support (CDS)
Tools and systems that provide healthcare providers with knowledge and patient-specific information to enhance decision-making. The Clinical Decision Support (CDS) system alerted the physician to potential medication interactions.
Define: Patient Portal
An online platform that allows patients to access their health information, communicate with healthcare providers, and manage appointments. The patient logged into the Patient Portal to view their lab results.
Define: Health Information Exchange (HIE)
The electronic sharing of health information among different healthcare organizations to improve the quality of care. The Health Information Exchange (HIE) facilitated the transfer of the patient's records to the new specialist.
Define: Data Entry
The process of inputting data into a computer system or database, often used for maintaining patient records. Accurate Data Entry is crucial for keeping patient records up to date.
Define: Charting Templates
Predefined formats used for documenting patient information in electronic health records to ensure consistency and efficiency. The nurse utilized Charting Templates to streamline the documentation process.
Define: Order Entry (CPOE - Computerized Provider Order Entry)
An electronic system that allows healthcare providers to place orders for medications, tests, and other services directly into a patient's record. The physician used Order Entry (CPOE) to prescribe medication efficiently.
Define: E-prescribing
The electronic generation and transmission of prescriptions from a healthcare provider to a pharmacy. The doctor opted for E-prescribing to improve prescription accuracy.
Define: Data Security
The protection of digital information from unauthorized access, corruption, or theft, especially in healthcare settings. The clinic implemented measures to enhance Data Security for patient records.
Define: Access Control
A security measure that regulates who can view or use resources in a computing environment, particularly sensitive patient information. Effective Access Control is essential to maintain patient confidentiality.
Define: Audit Log
A record that tracks all actions taken on a system, including access and modifications to sensitive information, ensuring accountability. The Audit Log revealed who accessed the patient's records and when.
Define: Encryption
A method of converting information or data into a code to prevent unauthorized access, commonly used for protecting patient data. The patient's information was secured through Encryption to comply with privacy regulations.
Define: User Authentication
The process of verifying the identity of a user before granting access to a system or resource, crucial for protecting sensitive information. User Authentication ensures that only authorized personnel can access patient records.