ABBREVIATIONS Flashcards
Current Dental Terminology
CDT
Case Mix Index
CMI
Clinical Documentation Support System
CDSS
Commission on Accreditation of Rehabilitation Facilities
CARF
Computerized physician order entry
CPOE
Conditions of Participation
COP
Data Elements for Emergency Departments
DEEDS
Diagnostic and Statistical Manual of Mental Disorders
DSM
Electronic Document Management System
EDMS
Electronic Health Records
EHR
Electronic Medical Records
EMR
Health Information Exchange
HIE
History and Physical
H&P
History of Present Illness
HPI
Logical Observation Identifiers Names and Codes
LOINC
Master patient index
MPI
Minimum Data Set
MDS
Medicare Provider Analysis and Review
MEDPAR
Office of Inspector General
OIG
Merit-based incentive payment system
MIPS
Outcome and Assessment Information Set
OASIS
Omnibus Budget Reconciliation Act of 1987
OBRA
Resident Assessment Instrument
RAI
Personal Digital Assistant
PDA
Picture archiving and communication systems
PACS
Problem-oriented medical record
POMR
Quality Improvement Organization
QIO
Recovery Audit Contractor
RAC
Regional Information Organization/ Regional Health Information Organization
RIO/RHIO
Resident Assessment Instrument
RAI
Skilled nursing facility
SNF
The Systemized Nomenclature of Medicine Clinical Terms
SNOWMED CT
Subjective, objective, assessment, plan
SOAP
Source-Oriented Record
SOR
Minimum Data Set
MDS
Office of the National Coordinator
ONC
Uniform Hospital Discharge Data Set
UHDDS
Past, family, and social histories
PFSH
Health Information Management
HIM
International Classification of Diseases, 10th revision, clinical modifications
ICD-10-CM
Current Procedural Technology
CPT
International Classification of Diseases, 10th revision, procedure coding systems
ICD-10-PCS
Health Care Procedure Coding System Level II
HCPCS