Clinical documentation Definitions

  • C

    clinical decision support system (CDSS)

    A CDSS, or clinical decision support system, is data analysis software or an application that care providers reference during treatment.

  • clinical document (HL7 clinical document)

    A clinical document is a written, printed or electronic record that provides evidence of medical care.

  • Clinical Document Architecture (CDA)

    Clinical Document Architecture (CDA) is a markup standard created by Health Level 7 International (HL7) that defines the structure of discharge summaries, progress notes and other medical records.

  • clinical documentation (healthcare)

    Clinical documentation (CD) is the creation of a digital or analog record detailing a medical treatment, medical trial or clinical test.

  • computer assisted coding system (CACS)

    A computer assisted coding system (CACS) is medical software that reviews healthcare forms, including electronic health records, and assigns appropriate medical codes to its findings.

  • computerized physician order entry (CPOE)

    A benefit of computerized physician order entry -- an electronic way to record patient data -- is that it eliminates errors caused by poor handwriting.

  • Current Procedural Terminology (CPT) code

    Current Procedural Terminology (CPT) codes are a uniform medical code set maintained and copyrighted by the American Medical Association and used to describe medical, surgical and diagnostic services.

  • L

    laboratory information system

    A laboratory information system (LIS) is software that collects, stores and produces reports from medical test data.

  • P

    population health management (PHM)

    Population health management (PHM) is a discipline within the healthcare industry that studies and facilitates care delivery across the general population or a group of individuals.

  • problem list

    A problem list is a document that catalogs a patient's health problems, including nontransitive illnesses, injuries and anything else that has or is affecting the patient.

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