Health Records And Data Content

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Electronic health record (EHR)

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A patient health record that maintained electronically so members of the entire healthcare team can access the information make up-to-the-minute decisions for the patient

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Documentation

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The process of recording health care data in the patient record

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Clinical information

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Information about the patient that is obtained through the clinical process; this information is found in medical test results, and vital sign collection

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Administrative information

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Demographic and health insurance information used to manage coding, medical billing, and family/care-giver information

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Legal documents

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Documents that are required to ensure that the EHR is a complete and legal document; these documents are required for every patient EHR

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Structured data entry

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Data entry that is entered through controlled computing such as drop down menus, radio buttons, or sentence builders

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Superbill/encounter form

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An itemized form used to document and enter; it contains the diagnosis and procedure performed

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Day sheet

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A daily register used for all business transactions, including charges, payments, and adjustments

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Encounter

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A documented interaction between the patient and health care provider

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Office of the National Coordinator for Health Information Technology (ONCHIT)

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The federal department responsible for establishing standards of health information management for all certified EHRs.

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Meaningful Use (MU)

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Standards established by the EHR initiative program that demonstrates the full use of the EHR

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Clinical decision support (CDS)

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Electronic patient centered tools embedded within the EHR software used to improve patient safety, establish healthcare protocols for specific conditions, and reduce duplicate care and its associated costs

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Practice management software (PMS)

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Electronic management of medical front office administrative actives such as entering patient demographics tracking medical billing and insurance information, scheduling appointments, and processing insurance and patient payments

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Continuity of care

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

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Cost of implementation

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Financial and intrinsic costs related to the implementation of EHR system. These can be significant financial costs, but include other costs such as employee training time

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Health information management professionals

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Certified professionals that are trained and educated on the most up-to-date standards of maintaining health information

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Fully integrated EHR

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An electronic health record software package with other health information software systems to fully manage health information electronically

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American Health Information Management Association (AHIMA)

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Professional organization that supports health information management professionals through education, certification, and standards development

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American Academy of Professional Coders (AAPC)

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Professionals organization that supports health information coders by providing certification, ongoing education, networking, and recognition

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American Association of Medical Assistants (AAMA)

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Professional organization that supports medical assistants searching for professional development, continuing education, approved educational programs, and certification information

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American Medical Technologists (AMT)

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A non-profit organization that provides allied health processionals with professionals certification services and membership

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Health Information Portability and Accountability Act (HIPAA)

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Federal legislation created to protect patient health information and to standardize the process of electronic data submission

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Privacy

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The patient's freedom to determine when, how much, and under what circumstances his or her medical information may be disclosed

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Security

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The effort made to protect patient health information from breach from internal and/or external factors

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Disclosure

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Providing access to,releasing, or transferring information to a person or health care entity

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Protected Health Information (PHI)

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Individually identifiable health information such as demographic information, billing information, medical record numbers, account numbers, physical or mental condition

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Authorization

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A document signed by the patient which gives the covered entity permission to use protected health information for specified purposes other than treatment, payment, or to disclose to a third party specified by the patient

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Minimum Necessary Standard

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A key provision of the HIPAA Privacy Rule requiring that covered entities limit unnecessary or inappropriate access to and disclosure of protected health information

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Consent

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Permission given from the patient to a covered entity for uses and disclosures of protected health information for treatment, payment, and health care operations

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Covered entities

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An entity that performs specific functions or activities that can involve the use or disclosure of protected health information

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Privacy Rule

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Part of HIPAA legislation that establishes standards for the use and disclosure of individually identifiable information

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Security Rule

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Part of HIPAA legislation that establishes guidelines for the covered entity to protect unauthorized access to protected health care information

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Confidentiality

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The obligation a health care facility has to keep patient's health information private

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Safeguards

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Measures taken to prevent interference with computer network operations and to avert security breaches involving the unauthorized use, disclosure, modification, erasure, or destruction of protected health information as established by HIPAA Security Rule

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Audit trails

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A record that traces a user's electronic footsteps by recording activity and transactions, including unsuccessful attempts to view authorized screens within the EHR system

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Screen Saver

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A feature on a desktop or laptop computer that locks user access after a period of inactivity; used to prevent unauthorized disclosure of PHI

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Password

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A unique sequence of characters used to authorize access to the EHR system

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Administrative Safeguards

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Practices that the medical practice or healthcare entity to adopt formal processes to prevent, detect, contain, and correct security violations

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Physical Safeguards

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Activities that ensure the physical security of electronic data to ensure against unauthorized access and protecting it from natural disasters

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Technical Safeguards

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Electronically based activities that protect and control access to PHI based on the principle of minimum necessary access

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Breach

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The access and/or release of PHI that was unauthorized by the patient

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Contingency Plan

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A physical safeguard plan to maintain EHR usage through times that access to the EHR may be blocked or limited

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Secondary use

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Information about the patient that is disclosed for the purpose of research and education. Does not include PHI or patient identifying information such as name

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Amendment

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A request from a patient to update the EHR clinical information

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List of disclosures

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A log of all patient disclosures documented in the patient EHR

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Office of Civil Rights (OCR)

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The government agency that accepts HIPAA violation complaints against healthcare facilities

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HITECH Act

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Legislation passed through the American road to recovery act which established guidelines for EHR implementation and use, and created meaningful use standards for measurements and research in the delivery if quality healthcare

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Centers for Medicare and Medicaid Services (CMS)

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A government agency that established provider documentation guidelines and medical coding protocols for all Medicare and Medicaid patient's

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Interoperability

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The ability for EHR systems to communicate with each other regardless of the health care facility

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Data Dictionary

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A set of definitions established in the EHR

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Office of the National Coordinator (ONC)

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A government agency responsible for establishing meaningful use standards for EHR implementation