Chapter 2 Key Terms

Question 1

Account Number

Answer 1

The number assigned to a patient to reference the care of that patient for the current visit. The account number is sometimes referred to as an encounter number, accession number, or registration number in different information systems

Question 2

Automated Dispensing Cabinet (ADC)

Answer 2

An electronic cabinet with drawers containing medications that are placed throughout the hospital for convenient access by healthcare providers to quickly administer medicines

Question 3

Blood Bank

Answer 3

A reserve of donated blood used to replenish blood supply of patients who experience extreme blood loss. Testing is performed on the blood to reduce risk of problems during blood transfusions

Question 4

Clinical Information System (CIS)

Answer 4

An information system directly related to the care of patients. (examples are the information systems for radiology, lab, surgery, pharmacy, and order entry)

Question 5

Cold feed

Answer 5

The real-time transfer of data from a source IS to a destination IS that does not receive acknowledgement of receipt of data. The data transfer is not guaranteed in cold feed. Other data transfers require a receipt of data acknowledgement, called an ACK message, that guarantees data was received

Question 6

Computerized Physician Order Entry (CPOE)

Answer 6

An order entry system designed specifically for doctors’ use

Question 7

Dashboard

Answer 7

An application’s graphic user interface (GUI) that provides status information at a quick glance and commands to manage the application

Question 8

Diagnostic Lab

Answer 8

A service used for advanced testing for disorders or diseases through laboratory analysis. Most diagnostic labs are remote from the hospital

Question 9

Dictation

Answer 9

A typed transcript of a recorded healthcare provider’s oral report of patient care as spoken into a voice recorder

Question 10

Electronic Medication Administrative Record (eMAR)

Answer 10

The medication administration record (MAR) recorded electronically using hand-held scanners at locations from the pharmacy to the patient bedside

Question 11

Emergency Department Information System (EDIS)

Answer 11

The information system that manages patient flow, orders, patient history, and record healthcare provides’ notes on patient’s visit, and more. The stage of a patient’s visit to the ED, who is caring for the patient, and other information are displayed on the tracking board from EDIS for convenient reference to a healthcare provider’s current caseload

Question 12

Health Information Exchange (HIE)

Answer 12

Sharing of patient information among multiple providers. These providers do not need to work in the same hospital to have access to patient information. Currently, this is typically done for hospitals in close geographic locations, but the goal is to make HIE nationwide

Question 13

Health Level & (HL7)

Answer 13

The standard protocol of formatting a message for healthcare interfacing. HL7 is ANSI certified. HL7 operates at the seventh or application layer of the OSI communication model

Question 14

Hospital Information System (HIS)

Answer 14

The primary information system used to manage data flow and maintain databases in a hospital. An HIS usually manages patient administration and order entry. HIS is sometimes called a healthcare information system (HIS)

Question 15

Information System (IS)

Answer 15

A computerized system used to facilitate the functions of an organization. An IS is a group of components that collect, process, store, and communicate information

Question 16

Interface

Answer 16

The connection between two information systems for the purpose of exchanging data

Question 17

Interface Engine

Answer 17

An application that serves as a communications hub and offers services to the messages as they travel through a network. These services include but are not limited to forwarding, filtering, translation, and queue management

Question 18

Lab Information System (LIS)

Answer 18

The information system responsible for orders, charging, and results of laboratory tests

Question 19

Master Patient Index (MPI)

Answer 19

The database of all MRNs and account numbers. This centralized database is responsible for preventing duplication of MRNs and account numbers

Question 20

Medical Record Number (MRN)

Answer 20

The number assigned to a patient to reference the care of that patient for all visits at one particular hospital. An MRN is unique to a patient within the hospital’s network

Question 21

Medication Administration Record (MAR)

Answer 21

The legal record of medication consumption in a hospital. The MAR tracks all medications in the hospital. Sometimes called drug charts

Question 22

Message

Answer 22

The information sent from one system to another

Question 23

Operative Record

Answer 23

A complete and detailed accounting of the surgical case happenings from preoperative through postoperative phases. This document is written to be used for legal reference if ever needed

Question 24

Order Entry

Answer 24

A component of an HIS where healthcare providers enter orders for patient care. Orders can be for procedures, imaging, or maybe tests. Order entry is sometimes written as OE but still read as “order entry.”

Question 25

Pathology Lab

Answer 25

A service that focuses on the diagnosis of diseases through laboratory analysis

Question 26

Perioperative Information System

Answer 26

The information system that manages patients in surgery. The perioperative IS starts with scheduling for surgery through discharge or transfer out of surgery. The perioperative IS works largely independent from other information systems because there is rarely a need for interaction with the other clinical departments

Question 27

Pharmacy Information System

Answer 27

The information system used by the pharmacy. The pharmacy IS supports but is not limited to order entry, management, dispensing of medications, monitoring, reporting, and charging

Question 28

Physician Portal

Answer 28

A user interface that access the HIS or HER/ EMR. The physician is where doctors go to view patient records, notes, and electronically sign off on charts

Question 29

Point-to-Point Connection

Answer 29

A one-to-one interface between two information systems. Point-to-point connections require the IS at each end of the connection to guarantee the delivery and interpretation of the data

Question 30

Radiology Information System (RIS)

Answer 30

The information system responsible for orders, charging, and results of medical imaging

Question 31

Requisitions

Answer 31

The list of requests sent to the nursing staff for collection of specimens from patients. The timing of the collection is sometimes critical of testing

Question 32

Solutions

Answer 32

Products or programs offered by vendors to provide an answer to a need

Question 33

Specimen

Answer 33

Sample of bodily fluids or tissue taken for analysis

Question 34

Surgical Summary Report

Answer 34

A brief accounting of the surgical case report for immediate referral during postoperative phase