continuity of care

the smooth continuation of care from one provider to another. this allows the patient to receive the most benefit and with no interruption or duplication of care

direct patient identifiers

used to link the information back to a specific person and can include payment, insurance, and personal demographic information

incidence

how often something happens

prognosis

the likely outcome of a disease, including the chance of recovery

electronic health record (EHR)

an electronic record that conforms to nationally recognized standards and contains health related information about a specific patient. it can be created, managed, and consulted by authorized clinicians and staff from more than one healthcare organization

quality control

a process to ensure the reliability of test results, often using manufactured samples with known values

vested

granted or endowed with particular authority, right, or property, to have a special interest in

baseline

an observation or value that represents the normal or beginning level of a measurable quality; used for comparison

hereditary

passed from parents to offspring through genes

hospitalist

a provider who oversees the general medical care of hospitalized patients; may include physicians, nurse practitioners, and physician assistants.

patient portal

a secure online website that gives patients 24 hour access to personal health information using a username and password

sign

something that is measured or observed by others; also called objective data. examples of signs include redness, swelling or edema, blood pressure, and pulse

symptom

something that is only perceived by the patient; also called subjective data. examples include pain, headache, dizziness, and nausea.

reverse chronologic order

a system of organization in which the most recent item is on the top and the oldest item is last

concise

using as few words as possible to express the message

no-show

a patient who fails to keep an appointment without giving advance notice

provisional diagnosis

a temporary diagnosis made before all test results have been received

audit trail

record of computer activity used to monitor users' actions within software, including additions, deletions, and viewing of electronic records

dictation

to say something aloud for another person to write down

obliteration

removal or destruction of all traces, do away with, destroy completely

transcription

to make a written copy of dictated material

unique user identification

each employee is assigned a unique name or number for identifying and tracking user identity

alphabetic filing

any system that arranges names or topics according to the sequence of the letters in the alphabet

direct filing system

a filing system in which materials can be located without consulting another source of reference

indirect filing system

a filing system in which an alphabetic cross-reference source must be used to determine the code assigned to the record

alphanumeric

describes systems made up of combinations of letters and numbers

tickler file

a chronologic file used as a reminder that something must be dealt with on a certain date

interoperability

the ability to work with other systems

promoting interoperability program

This program provides financial incentives for healthcare organizations that "meaningfully used" their certified EHR technology.

protected health information (PHI)

individually identifiable health information stored or transmitted by covered entities or business associates; includes verbal, paper, or electronic information

compliance

meeting the standards and regulations of the practice's established policies and procedures. can also mean cooperation.

computerized provider order entry (CPOE)

the process of entering medication orders or other provider instructions into the electronic health record

e-prescribing

the use of electronic software to communicate with pharmacies and send prescribing information. it takes the place of writing a prescription by hand and giving it to a patient; most new or refill prescriptions can be submitted electronically, cutting down on fraud and errors

interface

an interconnection between systems

covered entities

healthcare providers, health (insurance) plans, and claims clearinghouses that transmit protected health information electronically

permission

a reason for releasing or disclosing patient information under HIPAA

age of majority

the age at which the law recognizes a person to be an adult; it can vary by state

retention schedule

a method or plan for retaining or keeping health records and for their movement from active to inactive to closed

EHR

electronic health record

PMH

past medical history

UCD

usual child diseases

FH

family history

SH

social history

OH

occupational history

CC

chief complaint

HPI

history of present illness

OTC

over-the-counter (medication)

ROS

review of systems

CT

computerized tomography

MRI

magnetic resonance imaging

NPP

notice of privacy practices

HIPAA

health information portability and accountability act

SOMR

source oriented medical record

SOR

source oriented record

POMR

problem oriented medical record

EMR

electronic medical record

PHR

personal health record

PHI

protected health information

PMS

practice management software

CPOE

computerized provider order entry

ePHI

electronic protected health information

SOAP notes

subjective data, objective data, assessment, plan

CHEDDAR notes

chief complaint, history, examination, details of problem and complaints, drugs or dosages, assessment, return visit or referral

administrative safeguards

security officer is responsible for creating and carrying out security policies and procedures

physical safeguards

implementation of security policies for facility, workstations, or any work devices

technical safeguards

safeguards to prevent improper alteration, destruction of transmission of electronic personal health information

personal demographics

can include patient's full name, sex, gender, home address, social security number, and more

past medical history

can include childhood diseases, immunizations, allergies, and obgyn visits

family history

genetic health information about grandparents, parents, and siblings

social history

can include living situation, drug use, sexual history and preferences, hobbies, diet, tobacco use, and more

chief complaint

the reason for the patients visit

history of present illness

description of the illness, including a timeline history of the symptoms

physical examination

also known as a review of symptoms