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21 Cards in this Set
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- Back
- 3rd side (hint)
Administrative information
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patient-identifiable documentation used for administrative, regulatory, healthcare operations and payment (financial) purposes; should have same level of confidentiality as the legal health record
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Allied Health Professional
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professional who provide direct patient care
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CCHIT
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Certification Commission for Healthcare Information Technology
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organization that certifies electronic health records and EHR network developments of EHR system standards
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CPR
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Computer-based record
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term used in the 1900's which now is known as an electronic health record (EHR)
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Derived data
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factual details aggregated / summarized from a group of health records that has no unique patient identifiers; should have same level of confidentiality as legal health record
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Retention and Destruction
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processes for storing health info and destroying it when no longer needed; subject to federal regulations, accreditation standards, and often to state regulations
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EHR Collaborative
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consists of organizations representing key stakeholders in healthcare; worked with HL7 to publicize and refine the draft version of the EHR functional model in late 2003
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HIPAA
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Health Insurance Portability and Accountability Act
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Federal privacy rule established in 2003, providing a consistent set of privacy and security rules for the first time in regard to healthcare
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HL7
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Health Level Seven
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organization that develops standards related to healthcare delivery; worked with the EHR Collaborative to release the draft version of the EHR functional model in late 2003
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Health record
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the means that healthcare providers use to collect and store the clinical documentation they create for individual patients; property of the hospital or provider, however the information belongs to the patient; remains under the facility's physical control except in certain legal situations
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Legal health record
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the official business record created by or for the healthcare organization; the portion of the health record that will be disclosed unon request to parties outside the organization; does not affect discoverability of other info held by the organization
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contains documentation of healthcare services provided to a person during any aspect of healthcare delivery in any type of healthcare organization; contains patient-identifiable info, stored on any medium, collected / directly used in documenting healthcare or health status
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Longitudinal health record
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health record that includes all health-related info generated for an individual during his / her lifetime
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NCVHS
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National Committee on Vital and Health Statistics
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a public policy advisory board consisting of representatives from numerous healthcare, trade and professional organizations
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NCPDP Script
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National Council for Prescription Drug Programs Script
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specifies SCRIPT standards for the electronic transmission of prescription drug info between providers and pharmacies
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PACS
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Picture archiving and communications systems
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an electronic system containing portions of the EHR
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Protected health information
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used for the purposes of treatment, payment or healthcare operations; does not require patient authorization to allow providers access, use or disclosure; only minimum necessary info needed to satisfy the specified purpose can be used or disclosed, otherwise the patient's written authorization is required.
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Release and disclosure
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the collective processes that make health record info available to legitimate users
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ROI
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Release of information
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disclosure of patient information
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SNOMED CT
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Systematized Nomenclature of Medicine-Clinical Terms
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provides a common language for indexing, storing, retrieving and aggregating clinical data across specialties and healthcare providers; the National Library of Medicine purchased a license for it allowing its free use in the US
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Source-system data
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the data from which interpretations, summaries and notes are derived; must be evaluated for inclusion in the legal health record; examples include EKG tracings, lab values and radiological scans
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Working documents
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used by a provider in completing a final report; not part of the legal health record unless made available to others providing care to a patient
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