Clinical documentation Definitions
-
A
Allscripts
Allscripts is a vendor of electronic health record systems for physician practices, hospitals and healthcare systems.
-
ambulatory medical record (AMR)
An ambulatory medical record (AMR) is an electronically stored file of a patient’s outpatient medical records, which includes all surgeries and care that do not involve being admitted to a hospital.
-
C
Cerner Corp.
Cerner Corp. is a public company in North Kansas City, Mo., that provides various health information technologies, ranging from medical devices to electronic health records (EHR) to hardware.
-
Change Healthcare
Change Healthcare is a healthcare technology provider of revenue cycle management, payment management and health information exchange (HIE) solutions.
-
clinical decision support system (CDSS)
A clinical decision support system (CDSS) is an application that analyzes data to help healthcare providers make decisions and improve patient care.
-
Continuity of Care Document (CCD)
A Continuity of Care Document (CCD) is an electronic, patient-specific document detailing a patient's medical history.
-
Continuity of Care Record (CCR)
The Continuity of Care Record, or CCR, provides a standardized way to create electronic snapshots about a patient's health information.
-
Current Procedural Terminology (CPT) code
Current Procedural Terminology (CPT) is a medical code set that enables physicians and other healthcare providers to describe and report the medical, surgical, and diagnostic procedures and services they perform to government and private payers, researchers and other interested parties.
-
D
digital health (digital healthcare)
Digital health, or digital healthcare, is a broad, multidisciplinary concept that includes concepts from an intersection between technology and healthcare.
-
E
electronic health record (EHR)
An electronic health record (EHR) is an individual's official health document that is shared among multiple facilities and agencies.
-
electronic intensive care unit (eICU)
An Electronic Intensive Care Unit (eICU) is a form or model of telemedicine where state-of-the-art technology is used to provide an additional layer of critical care service to patients.
-
Epic Systems
Epic Systems is one of the largest providers of health information technology, used primarily by large U.S. hospitals and health systems to access, organize, store and share electronic medical records.
-
H
Health IT (health information technology)
Health IT (health information technology) is the area of IT involving the design, development, creation, use and maintenance of information systems for the healthcare industry.
-
L
legal health record (LHR)
A legal health record (LHR) refers to documentation about a patient's personal health information that is created by a healthcare organization or provider.
-
M
medical scribe
A medical scribe is a professional who specializes in documenting patient encounters in real time under the direction of a physician.
-
Meditech (Medical Information Technology Inc.)
Meditech (Medical Information Technology Inc.) is an electronic health record vendor that holds a 19% market share in the hospital industry, but faces intense competition.
-
P
personal health record (PHR)
A personal health record (PHR) is an electronic summary of health information that a patient maintains control of themselves, as opposed to their healthcare provider.
-
PHI breach (protected health information breach)
A PHI breach is unauthorized access, use or disclosure of individually identifiable health information that is held or transmitted by a healthcare organization or its business associates.
-
Project Nightingale
Project Nightingale is a controversial partnership between Google and Ascension, the second largest health system in the United States. The partnership, which began in 2018, has provided Google with access to the medical records of over 50 million people.
-
R
registered health information technician (RHIT)
A registered health information technician (RHIT) is a certified professional who stores and verifies the accuracy and completeness of electronic health records.
-
RHIA (Registered Health Information Administrator)
An RHIA, or registered health information administrator, is a certified professional who oversees the creation and use of patient health information, including analyzing that data.