Book 3- Ch 1

Front 1

Account Ledger

Back 1

In accounting billing document that lists Services provided, co-payments made by the patient, reimbursement received from the patient's insurance company, and outstanding amount owed.

Front 2

Audit

Back 2

A review of employee activity within the EHR system systems, including an examination of which files were accessed or modified, when, and why.

Front 3

Certification commission for healthcare information technology (cchit)

Back 3

I recognized certification body for EHR systems and their Networks. The cchit is an independent, voluntary private-sector initiative whose goal is to accelerate the adoption of health information technology.

Front 4

Chief complaint

Back 4

The patient stated primary reason for seeking treatment.

Front 5

Clinical decision-support (CDS)

Back 5

A set of patient-centered tools embedded within EHR software that can be used to improve patient safety, and sure that care conforms to published protocol for specific conditions, and reduce duplicate or unnecessary care and its Associated costs.

Front 6

Computerized provider order entry (cpoe)

Back 6

Mhr function that allows a physician or other prescriber to order medications and tests using an automated format; cpoe can reduce prescribing errors, delays, and duplication and simplify inventory and billing processes.

Front 7

Continuity of care

Back 7

A key aspect of quality that encompasses planning and coordination of care, communication among members of the healthcare team, and accessibility and transportability of information.

Front 8

Copayment

Back 8

A fixed sum of money that is paid by the patient, usually at the time medical services are rendered.

Front 9

Day sheet

Back 9

A register for daily business transactions; also called a day Journal.

Front 10

Documentation

Back 10

The process of recording data about a patient's health history and Status, including clinical observations and progress notes, diagnosis of illness and injuries, plans of care, laboratory and imaging test results, Medical Treatments prescribed or administered, surgeries performed, and outcomes; the term can also refer to the chronologic record that results from such data entry.

Front 11

Electronic health record (EHR)

Back 11

A computerized patient health record that allowed to go to electronic management of patients health information by multiple Healthcare Providers and stores of patience contact information, legal documents Kama demographic data, and administrative information; the term can also refer more broadly to A system that manages such records.

Front 12

Electronic transcription

Back 12

Data entry into the EHR using handwriting recognition, voice recognition, Electronics sentence building, scanning, and other means.

Front 13

Encounter

Back 13

It documented interaction or visit between a patient and a healthcare provider.

Front 14

Interoperability

Back 14

The ability to separate EHR systems to share information in compatible formats.

Front 15

Patient information form (PIF)

Back 15

A form used to gather data about the patient, including basic demographic information, medical insurance data, and emergency contact.

Front 16

Practice management software (PMS)

Back 16

Software used in a medical office to accomplish administrative (non clinical) tasks, including entry of patient demographics, record-keeping for insurance and other billing transactions, appointment scheduling, and advanced accounting functions.

Front 17

Structured data entry

Back 17

Documentation using controlled vocabulary the preloaded data, drop down boxes, radio buttons, and sentence builders.

Front 18

Third-party payer

Back 18

A party other than the patient, Sprouts, parent, or Guardian who is responsible for paying all or part of the patient's medical costs, typically the insurance company.