Chapter 2 Key Terms Flashcards
Learn the definitions of the Key Terms used within the Healthcare and IT world
Account Number
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
Automated Dispensing Cabinet (ADC)
An electronic cabinet with drawers containing medications that are placed throughout the hospital for convenient access by healthcare providers to quickly administer medicines
Blood Bank
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
Clinical Information System (CIS)
An information system directly related to the care of patients. (examples are the information systems for radiology, lab, surgery, pharmacy, and order entry)
Cold feed
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
Computerized Physician Order Entry (CPOE)
An order entry system designed specifically for doctors’ use
Dashboard
An application’s graphic user interface (GUI) that provides status information at a quick glance and commands to manage the application
Diagnostic Lab
A service used for advanced testing for disorders or diseases through laboratory analysis. Most diagnostic labs are remote from the hospital
Dictation
A typed transcript of a recorded healthcare provider’s oral report of patient care as spoken into a voice recorder
Electronic Medication Administrative Record (eMAR)
The medication administration record (MAR) recorded electronically using hand-held scanners at locations from the pharmacy to the patient bedside
Emergency Department Information System (EDIS)
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
Health Information Exchange (HIE)
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
Health Level & (HL7)
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
Hospital Information System (HIS)
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)
Information System (IS)
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
Interface
The connection between two information systems for the purpose of exchanging data
Interface Engine
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
Lab Information System (LIS)
The information system responsible for orders, charging, and results of laboratory tests
Master Patient Index (MPI)
The database of all MRNs and account numbers. This centralized database is responsible for preventing duplication of MRNs and account numbers
Medical Record Number (MRN)
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
Medication Administration Record (MAR)
The legal record of medication consumption in a hospital. The MAR tracks all medications in the hospital. Sometimes called drug charts
Message
The information sent from one system to another
Operative Record
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
Order Entry
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.”
Pathology Lab
A service that focuses on the diagnosis of diseases through laboratory analysis
Perioperative Information System
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
Pharmacy Information System
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
Physician Portal
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
Point-to-Point Connection
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
Radiology Information System (RIS)
The information system responsible for orders, charging, and results of medical imaging
Requisitions
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
Solutions
Products or programs offered by vendors to provide an answer to a need
Specimen
Sample of bodily fluids or tissue taken for analysis
Surgical Summary Report
A brief accounting of the surgical case report for immediate referral during postoperative phase
