EHR Specialist
Terms that would be used in an Electronic Health Record Specialist Exam.
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| A record of patient medical and health care information accessible to providers and other staff members with login credentials regardless of location | Electronic Health Record - E.H.R. |
| A document that is required by law to inform a patient how the organization will use their health care information | Notice of Privacy Practices - N.P.P. |
| An independent, not-for-profit group that certifies electronic health records and networks for health information exchange. | Certification Commission for Healthcare Information Technology (CCHIT) |
| The number used by the hospital as a systematic documentation of a patient | Medical Records Number - M.R.N. |
| Use of computer system to enter and process prescriptions and treatments at the point of care | Computerized Provider Order Entry - C.P.O.E. |
| Organization of American physicians, the objective of which is to promote the science and art of medicine and the betterment of public health. | American Medical Association (AMA) |
| An electronic record containing a patient's prescribed medications administration times, and who administered it. | Electronic Medication Administration Record - E.M.A.R. |
| A legal document that contains information about a patient's treatment choices when they are unable to make health care decisions. | Advance Directives |
| The number used by the hospital as a systematic documentation of a patient. | Medical Records Number (MRN) |
| A patient's authorization to allow health insurance payment to be made directly to the provider of service. | Assignment of Benefits |
| A document that is required by law to inform a patient how the organization will use their health care information. | Notice of Privacy Practices (NPP) |
| Use of a computer system to enter and process prescriptions and treatments at the point of care. | Computerized Provider Order Entry (CPOE) |
| An electronic record containing a patient's prescribed medications administration times, and who administered it. | Electronic Medication Administration Record (eMAR) |
| Technology that are frequently used of the field like Bar Code Scanners, Cameras, Printers, Signature pads, Fax machines. | Peripheral Devices |
| Documentation of an individual's health information that is tracked in both physical and electronic formats. | Hybrid Health Record (HHR) |
| Healthcare software that manages the day-to-day operations of a clinic, such as appointment scheduling, billing and other administrative tasks. | Practice Management System (PMS) |
| System that uses both paper and electronic based processing for documentation of health information. | Hybrid Record State |
| A sub-system of the hospital information system, which is designed to assist pharmacists in safely managing the medication process. | Pharmacy Information System (PIS) |
| A healthcare software solution that processes, stores, and manages patient data related to laboratory processes and testing. | Laboratory Information System (LIS) |
| Medical imaging technology used primarily in healthcare organizations to securely store and digitally transmit electronic images and clinically-relevant reports. | Picture Archiving and Communication System (PACS) |
| The practice of acquiring, analyzing, and protecting digital and traditional medical information vital to providing quality patient care. | Health Information Management (HIM) |
| A system used by physicians and other healthcare providers to classify and code all diagnoses, symptoms and procedures recorded in conjunction with hospital care in the United States. | International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) |
| Federal law that required the creation of national standards to protect sensitive patient health information from being disclosed without the patient's consent or knowledge. was enacted on August 21, 1996, | Health Insurance Portability and Accountability Act (HIPAA) |
| Encouraged healthcare providers to adopt electronic health records and improved privacy and security protections for healthcare data. This was achieved through financial incentives for adopting EHRs and increased penalties for violations of the HIPAA Privacy and Security Rules. | Health Information Technology for Economic and Clinical Health Act (HITECH) |
| Nicknamed the Recovery Act, was a stimulus package enacted by the 111th U.S. Congress and signed into law by President Barack Obama in February 2009. | American Recovery and Reinvestment Act (ARRA) |
| It is used to share summary information about the patient within the broader context of the personal health record. | Continuity of Care Document (CCD) |
| The ability of different information systems and software applications to communicate and exchange data and use the information exchanged. | Interoperability |
| A legal document that contains information about a patient's treatment choices when they are unable to make health care decisions. | Advance Directives |
| A patient's authorization to allow health insurance payment to be made directly to the provider of service. | Assignment of Benefits |
| A program designed to prompt providers with clinical decisions. | Clinical Decision Support System (CDSS) |
| Health information that is specific to a patient. | Protected Health Information (PHI) |
| Minor disclosures that may occur during legitimate use of information even when reasonable security measures are in place. | Incidental Disclosures |
| Protecting private health information by limiting access based on need. | Minimum Necessary Concept |
| Looking at an organization's processes, identifying where and how much data could be accessed inappropriately, and taking steps to prevent it. | Risk Analysis and Management |
| Limiting access to work areas, as well as proper disposal and re-use of electronic media and devices. | Physical Safeguards |
| Password protection, a secure server with dual authentication systems for remote access, and backup systems that maintain an exact copy of each patient record. | Technical Safeguards |
| Can include having designated employees responsible for security, training, staff education, and having a system for evaluating effectiveness of security measures. | Administrative Safeguards |
| The main reason for the visit as stated by the patient. | Chief Complaint |
| A summary of what the patient tells the clinical staff about their history, family history, problems, concerns, symptoms, and goals. | Subjective Elements |
| Consists of the provider asking questions about symptoms related to specific body organs systems. | Review Of Systems |
| Internal policies designed to prevent claim errors, fraud, and abuse. | Compliance Programs |
| The ability of different information systems and software applications to communicate and exchange data and use the information exchanged. | Interoperability |
| Routine health care that includes screenings, check-ups, and patient counseling to prevent illnesses, disease, or other health problems. | Prevent Care Screening |
| A person or entity that provides services to a covered entity that involves the disclosure of PHI. | Business Associates |
| The U.S. federal agency that works with state governments to manage the Medicare program, and administer Medicaid and the Children's Health Insurance program. | Center for Medicare and Medicaid (CMS) |
| A third-party entity that has contact with protected health information to provide services unrelated to treating patients. | Business Associate |
| A legal contract dictating a business associate to comply with protection of protected health information under the HIPAA Privacy Rule. | Business Associate Agreement |
| Any medical or health care service, organization, agency, or individual that has protected health information. | Covered Entity |
| The process of removing personal health information that can clearly identify a patient. | De-Identification |
| Examination of in-house government and financial processes for appropriateness and accuracy. | Internal Audit |
| To adhere to the professional standards of care. That follows as Standards of quality, interoperability, functionality, privacy, and security. | Regulatory Compliance |
| Minor disclosures that may occur during legitimate use of information even when reasonable security measures are in place. | Incidental Disclosures |
| Encouraged healthcare providers to adopt electronic health records and improved privacy and security protections for healthcare data. This was achieved through financial incentives for adopting EHRs and increased penalties for violations of the HIPAA Privacy and Security Rules. | Health Information Technology for Economic and Clinical Health Act (HITECH) |
| Limiting access to work areas, as well as proper disposal and re-use of electronic media and devices. | Physical Safeguards |
| Password protection, a secure server with dual authentication systems for remote access, and backup systems that maintain an exact copy of each patient record. | Technical Safeguards |
| Can include having designated employees responsible for security, training, staff education, and having a system for evaluating effectiveness of security measures. | Administrative safeguards |
| Cataloging system for diagnosis codes that track various health interventions taken by medical professionals. | International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) |
| Cataloging system for procedural codes that track various health interventions taken by medical professionals. | International Classification of Diseases, 10th Revision, Procedure Coding System (ICD-10-PCS) |
| A coding classification system in which codes are used to bill outpatient procedures and physician services. | Healthcare Common Procedure Coding System (HCPCS) "LEVEL 1" |
| A coding classification system in which codes are used to bill professional services, supplies, and products. | Healthcare Common Procedure Coding System (HCPCS) "LEVEL 2" |
| A coding classification system used to report professional services and procedures provided to a patient at ambulatory care centers, medical clinics, and other outpatient care facilities. | Current Procedural Terminology, 4th Edition (CPT-4) |
| Has the ability to accurately generate medical codes directly from clinical documentation. | Computer Assisted Coding (CAC) |
| Documentation that is meant to assist clinicians by minimizing time spent on documentation and maximizing time for patient care. | Point-Of-Care (POC) Documentation |