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116 Cards in this Set

  • Front
  • Back
Text that is added to a document after it has been finalized.
Pop-ups or reminders. An automated warning system such as clinical alerts, preventive health maintenance, medication interactions etc.
Ambulatory Care
Medical care provided on an outpatient basis.
A system function that allows an explanatory note or diagram to be added to an image.
(Application Service Provider)
Third-party entity that deploys, hosts and manages software from a centrally managed host facility (offsite). "Software-as-a-service" model.
Audit Trail
Security system that tracks a user's access, deletion, or modification of data. Chronological record of system resource usage.
The verification of the identity of a person or process.
A data transmission rate; the maximum amount of information (bits/second) that can be transmitted along a channel.
Bar Code
A printed horizontal strip of vertical bars which represent decimal digits used for identification.
Automated methods of recognizing a person based on a physiological characteristic such as fingerprints, retina, voice etc.
Short for Web browser, a software application used to locate and display Web pages.
Case Management
Process of identifying individuals at high risk for problems associated with complex health care needs and assessing opportunities to coordinate care to optimize outcome.
Medical Record
Chart Note
Document written by clinician or provider describing details of a patient's encounter (progress note).
Client/Server architecture
Information-transmission arrangement in which client program sends a request to a server. Request received, server disconnects and processes, reconnects and sends info to client.
Clinical Data Repository (CDR)
A real-time database that consolidates data from a variety of clinical sources to present a unified view of a single patient. Clinicians can retrieve data for a single patient instead of an entire population.
Clinical Decision support system (CDSS)
Software designed to match individual patient characteristics to knowledge bases to generate patient-specific assessments/recommendations.
Clinical Guidelines (Protocols)
Recommendations based on latest available evidence for appropriate treatment and care of patient's condition.
Clinical messaging
Communication of clinical information within the electronic medical record to other healthcare personnel
Clinical Practice Guidelines
Clinical Performance Measures
CPOE (Computerized Provider Order Entry), CPOE
Act of clinician entering an order for patient services into an information system., Computerized provider order entry
CPR (Computerized Patient Record, Computer-Based Patient Record)
Electronically maintained information about an individual's lifetime health status and healthcare from all specialties.
CPT (Current Procedural Terminology), CPT
CPT codes provide a uniform language that accurately describes medical, surgical, and diagnostic services., Current Procedural Terminology
Data conversion
Conversion of data from one software to another.
Data Encryption Standard (DES)
Widely-used method of data encryption using a private (secret) key.
Data Integrity
Validity of data. Data has not been altered, or destroyed in an unauthorized manner.
Data Mining
A group of data elements relevant for a particular use.
Data Structure
A way to store and organize data in order to facilitate access and modifications.
Collection of information organized in a way that a computer program can quickly select desired pieces of data.
Database management system (DBMS)
Set of computer programs for organizing the information in a database.
DICOM (Digital Imaging and Communications in Medicine
Standard to aid the distribution and viewing of medical images, such as CT scans, MRIs, and ultrasound.
Process by which a physician records his/her notes about a patient. Recording is intended for reproduction in written word.
Digital Signature
Advanced Electronic Signature. A hand-written signature used to create a digital image to use in signing documents.
Discrete Data
Values belonging to the data are distinct and separate. Date is more easily reportable as opposed to nondiscrete or unstructured data.
Document Imaging
Converting paper documents into an electronic format through scanning process.
Process of recording information
Document Management
System involving scanning, categorizing, and storing vital patient documents.
DOQ-IT (Doctors Office Quality Information Technology)
2-year special study designed to improve quality of care, patient safety, and efficiency for services provided to Medicare beneficiaries by promoting adoption of EHR's and IT in primary physician offices.
E & M Coding (Evaluation and Management Coding)
Documentation guidelines from Center for Medicare and Medicaid Services.
Electronic Data Interchange
EHR (Electronic Health Record), EHR
Electronic repository of information regarding the health of an individual., Electronic health record
Electronic Superbill
Electronic encounter form for coding and billing.
EMR (Electronic Medical Record), EMR
Provider-based medical record that includes all health documentation for one person covering all services provided within an enterprise., Electronic medical record
EOE (Electronic Order Entry)
Program moves hand-written and verbal orders to computer-based entry.
EPR (Electronic Patient Record)
Computerized Patient Record.
Process of converting messages or data into a form that cannot be read without decrypting or deciphering it.
Prescribing medication through an automated data-entry process and transmitting to participating pharmacies.
Evidence based medicine (EBM)
Integration of best research evidence with clinical expertise to aid in the diagnosis and management of patients.
Face Sheet
Summary Screen or Patient Dashboard.
Fat Client
Network computer with a hard disc drive as opposed to a thin client wit no disc drive.
System designed to prevent unauthorized access to or from a private computer network.
Listing of prescription drugs established by a particular drug plan including both Brand name and Generic drugs.
File Transfer Program
Graphical User Interface (GUI)
Program interface that takes advantage of the computer's graphics capabilities to make the program easier to use.
Help Desk
Service and support desk.
HIPAA (Health Insurance Portability and Accountability Act)
Standardized mechanism for electronic data interchange (EDI), security, confidentiality of healthcare-related data.
HL7 (Health Level 7), HL7
Goal of developing international set of open standards for data format and content that allows different health information systems to easily and effectively communicate., Health level system
Hot Keys
One- or two keystroke command that switches the user to a different program.
HM (Health Maintenance)
Preventive Health Maintenance--system of guidelines of tests and procedures that have proven value in disease prevention.
ICD-9 or ICD-10 (International Classification of Diseases)
Classification and coding of diseases and injuries.
Application of computer technology to the management of information.
Allows for secure communication between enterprise applications.
Successful communication between end-users across a mixed environment of different domains, networks, facilities and equipment.
Internet Service Provider
IT (Information Technology)
Development, installation, and implementation of computer systems and applications.
Small computer workstations which allow information to be input.
LAN (Local Area Network)
Supplies networking capability to a group of computers in close proximity to each other.
Legacy System
System considered old and possibly out-dated.
Legacy System Integration
Integration of data between a legacy system and some other software program most commonly using Hl-7 standards.
LEPR (Longitudinal Patient Record)
EHR that includes all healthcare information from all sources.
Symbol, name, or key (Macro key) that represents a list of commands, actions, keystrokes or blocks or text.
System for communication among two or more computers
OCR (Optical Character Recognition)
Recognition of printed or written characters by a computer.
PACS (Picture Archiving and Communication System), PACS
System for storage and distribution of digital radiology images over a networked environment., Picture archiving and communications systems
Patient Portal
Allows patients and providers to communicate over the internet in a secure environment.
PDA (Personal Desk Assistant or Personal Digital Assistant)
Hand-held device with multitude of uses allowing for mobility.
Protected health information
Preventive Health Maintenance
PHR (Personal Health Record), PHR
Includes all healthcare information from all sources, compiled and maintained by the patient., Patient health record
Basic technology of a computer system's hardware and software that defines how a computer is operated and determines what software can be used.
Practice Management (biling) system
Patient Medical Record Information
Practice Management System
Point and Click
Allowing activation of commands by moving the cursor over certain areas or icons and clicking a pointing device.
Refers to time while with the patient, either bedside or during an encounter.
Website considered as an entry point to other websites.
Problem list
Diagnosis list.
Clinical Guidelines
Pull Down Menu
Drop-down menu of commands or options that appear when you select an item with a mouse.
QIO (Quality Improvement Organization), QIO
Medicare QIO program. Associated with DOQ-IT program. Work to refine care delivery systems., Quality Information Organization (Formerly PRO - Peer Review Organization
Primary mechanism for retrieving information from a database.
Radio Frequency Identification
ROI (Return on Investment), ROI
Measuring an increase in revenue, a decrease in expense or an avoidance of expense., Return on investment
How well a hardware or software system can adapt to increased demands.
Effort to create a secure computing platform designed so the agents can only perform actions that have been allowed.
Server Farm
Group of networked servers housed in one location.
Single sign-on (SSO)
Mechanism whereby a single action of user authentication and authorization can permit a user to access all computers and systems where he/she has access permission.
SNOMED-CT (Systematized Nomenclature of Medicine-Clinical Terms)
Clinical, health care terminology and infrastructure.
SOAP note format
A format for medical documentation, subject, objective, assessment, plan
Speech Recognition
Ability of a computer to understand the spoken word for the purpose of receiving commands and transforming speech into text.
Structured Data
Data managed by technology that allows for querying and reporting against predetermined data types and understood relationships.
T1 Line
T1 carrier is a commonly used digital internet connection line in the US supporting date rates of 1.544 MBits per second.
Tablet PC
computer shaped in the form of a notebook. User can use a stylus to operate the computer without having to have a keyboard or mouse.
Often called library or dictionary. Pre-defined choices of pick-lists designed to streamline the documentation process.
Thin client
computer network without a hard drive.
Process by which medical transcriptionists convert physician's dictation into written words.
Touch screen
An input device that allows the user to interact with the computer by touching the display screen.
Unstructured data
Data such as free-text. Computer cannot automatically extract properties and relationships.
Voice Recognition
See Speech Recognition.
Way to communicate through a dedicated server securely to a corporate network over the internet., Virtual private network
Way to communicate through a dedicated server securely to a corporate network over the internet., Virtual private network
WAN (Wide Area Network)
Computer network that spans a larger geographical area than a LAN
Lecture, presentation, workshop, or seminar that is transmitted over the Web.
Web Portal
Website considered as an entry point to other websites.
A system employing no connecting wire between the transmitting and receiving stations.
Automation of a process, in whole or in part, during which documents, information or tasks are passed from one participant to another for action according to a set of procedureal rules.