Clinical documentation Definitions

  • B

    biomedical informatics

    Biomedical informatics is the branch of health informatics that uses data to help clinicians, researchers and scientists improve human health and provide healthcare.

  • 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 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)

    Computerized physician order entry (CPOE), also known as computerized provider order entry or computerized practitioner order entry, refers to the process of a medical professional entering and sending medication orders and treatment instructions electronically via a computer application instead of on paper charts.

  • 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.

  • I

    ICD-10-CM (Clinical Modification)

    The ICD-10-CM (Clinical Modification) is 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.

  • L

    laboratory information system

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

  • P

    personal health record (PHR)

    A personal health record (PHR) is a collection of health-related information that is documented and maintained by the individual it pertains to.

  • 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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