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21 Cards in this Set

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Administrative information
patient-identifiable documentation used for administrative, regulatory, healthcare operations and payment (financial) purposes; should have same level of confidentiality as the legal health record
Allied Health Professional
professional who provide direct patient care
CCHIT
Certification Commission for Healthcare Information Technology
organization that certifies electronic health records and EHR network developments of EHR system standards
CPR
Computer-based record
term used in the 1900's which now is known as an electronic health record (EHR)
Derived data
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
Retention and Destruction
processes for storing health info and destroying it when no longer needed; subject to federal regulations, accreditation standards, and often to state regulations
EHR Collaborative
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
HIPAA
Health Insurance Portability and Accountability Act
Federal privacy rule established in 2003, providing a consistent set of privacy and security rules for the first time in regard to healthcare
HL7
Health Level Seven
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
Health record
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
Legal health record
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
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
Longitudinal health record
health record that includes all health-related info generated for an individual during his / her lifetime
NCVHS
National Committee on Vital and Health Statistics
a public policy advisory board consisting of representatives from numerous healthcare, trade and professional organizations
NCPDP Script
National Council for Prescription Drug Programs Script
specifies SCRIPT standards for the electronic transmission of prescription drug info between providers and pharmacies
PACS
Picture archiving and communications systems
an electronic system containing portions of the EHR
Protected health information
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.
Release and disclosure
the collective processes that make health record info available to legitimate users
ROI
Release of information
disclosure of patient information
SNOMED CT
Systematized Nomenclature of Medicine-Clinical Terms
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
Source-system data
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
Working documents
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