Clinical documentation Definitions

Search Definitions
  • A

    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

    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.

  • clinical documentation

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

  • 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.

  • What is a clinical trial?

    Clinical trials, also known as clinical research studies, are carefully designed investigations involving volunteer human participants to evaluate the safety, efficacy and outcomes of medical or surgical interventions.

  • What is Cerner Corp.?

    Cerner Corp., now known as Oracle Health following its 2022 acquisition by Oracle, is a prominent health IT company based in North Kansas City, Missouri.

  • What is Change Healthcare?

    Change Healthcare is a healthcare technology provider specializing in revenue cycle management, payment management and health information exchange solutions.

  • What is 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

    What is digital health (digital healthcare)?

    Digital health, also known as digital healthcare, is the use of digital technologies in healthcare.

  • E

    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, also known simply as Epic, 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.

  • What is an electronic health record (EHR)?

    An electronic health record (EHR) is an individual's official health document that's shared among multiple facilities and agencies.

  • H

    What is 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.

  • What is Meditech Medical Information Technology, Inc.?

    Meditech (Medical Information Technology, Inc.) is a privately held company headquartered in Westwood, Mass., that provides health information technology (health IT) solutions, primarily electronic health record (EHR) systems.

  • N

    national provider identifier (NPI)

    A national provider identifier (NPI) is a unique ten-digit identification number required by the Health Insurance Portability and Accountability Act (HIPAA) for covered healthcare providers in the United States.

  • 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.

  • 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.

  • What is PHI (protected or personal health information)?

    Protected health information (PHI), also referred to as 'personal health information,' is the demographic information, medical histories, test and laboratory results, physical and mental health conditions, insurance information and other data that a healthcare professional collects to identify an individual and determine appropriate care.

  • What is PHI breach (protected health information breach)?

    A PHI (protected health information) 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.

  • R

    What is a registered health information technician (RHIT)?

    A registered health information technician (RHIT) is a certified professional who creates and verifies electronic health records.

  • What is RHIA (Registered Health Information Administrator)?

    A registered health information administrator (RHIA) is a certified professional who oversees the creation and use of electronic health records (EHRs).