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EHRC > DPRC Vocabulary > Flashcards

DPRC Vocabulary Flashcards

0
Q

Formulary

A

Subset of drugs physicians can order that organization decides

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1
Q

Pharmacy

A
  • receives, and process medication orders
  • has features such as pharmacy billing, inventory management, generation of medication labels, fills lists, patients profiles, and support for clinical pharmacy activities such as advanced drug information for pharmacists
  • has tight intergration with provider order entry and clinical decision support systems or modules
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2
Q

EDI

A

Electronic data interchange (EDI)

-capability to send transactions to clearing houses, which send them on to payers

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3
Q

Document Imaging

A

4

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4
Q

PACS

A

Picture archiving and communication system
-stores x-ray, CAT scan, ultrasound, and other types of medical images
-allows clinicians to view the images on a computer screen
High-end computer screens associated with PACS systems allow for diagnostic-quality images to be interpreted by qualified personnel, thus eliminating the need for film in most cases

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5
Q

RIS

A

Radiology information system

  • divisions include patient scheduling, result reporting, and image tracking
  • Stores, organizes, and distributes patient radiological data, such as a report of the interpretation by radiologist of an x-ray
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6
Q

Materials Management

A
  • supports the procurement of capital equipment (CAT scans, hospital beds, and dialysis machines) and operational supplies (bandages, linen, and office supplies) and inventory functions associated with supplies
  • automates parts of the purchasing, ordering, shipping, and storage processes
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7
Q

General Ledger

A
  • generates income and statement and balance sheets
  • what money is coming in and going out
  • every business must have one
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8
Q

LIS

A

Laboratory information system

  • divisions include chemistry, hematology, microbiology, and toxicology
  • process orders for clinical laboratory services or tests
  • connects with laboratory machines so measurements of patients specimens are automatically transferred to LIS and on to the HIS where they are made available to clinicians
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9
Q

Utilization Review

A

8

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10
Q

HIS

A

Health information system

  • a computer based system that holds and updates patient-related information and records
  • has a 2 folded purpose
  • ——-1. support direct clinical care
  • ——-2. support the management and administration related to such care
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11
Q

HIT

A

Healthcare information technology

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12
Q

ADT

A

Admission,discharge, and transfer (ADT)

  • called the hotel function of healthcare information systems
    (admit) –allows staff to admit patients to a healthcare facility and a specific unit or bed within the facility
    (transfer) –move the patient within the facility or across facilities within the enterprise
    (discharge) —-discharge the patient from the facility
  • -has census capability
  • –listing of patients in a clinical unit
  • –used to “select” a patient record
  • has notification and Interface capability
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13
Q

EBM

A

Evidence-Based Medicine
….Use of Standard and Best Practice
-ensures that diagnostiic and therapeutic services represent “best practice”
-reduces variation and error
—examples
—-using order sets to ensure medication standard is used for stroke treatment in ED
—-Use of surgery check-lists
——prevent wrong patient and wrong site events
——ensure antibiotics given prior to surgery
—-Use of alerts and reminders for
—–preventative services for chronic diseases
—–pediatric vaccinations

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14
Q

AR

A

Accounts Receivable

—collections management

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15
Q

BCMA

A

Bar-code medication administration
-also known as barcode point of care (BPOC) and electronic medication administration record (eMAR)
-

16
Q

Centralized HIS

A

one vendor provides most or all of the divisions or modules of the healthcare information system

17
Q

Best of Breed

A
  • one HIS provides several of the administrative functions and possibly clinical or financial functions, but with a significant number of additional modules from different vendors.
  • requires interfacing between vendor products to enable smooth functioning of the system as a whole
18
Q

E-Prescribing

A

an extension of CPOE for medications generally used in outpatient settings

  • -physicians or other prescribers use the EHR to “write” a prescription
  • -safety checks are made by the EHR at the time of writing
  • -the module can print out the prescription and educational material
  • -the prescription is usually sent immediately and electronically to the patient’s pharmacy of choice
  • -the pharmacist can fill it without having to try to decipher potentially poor provider handwriting
19
Q

CDS

A

Clinical Decision Support

  • -system uses EMR data to generate alerts and reminders to clinicians and care providers
  • –examples
  • —-system generates alerts during CPOE and E-Prescribing
  • —-system generates alert during radiology procedure that patient is allergic to dye
  • —-during outpatient visit, system generates a list that patient needs pneumonia vaccination
  • —-for chromic disease management, system generates a list of diabetic patients who have not a retinal exam in the last two years
20
Q

MPI module

A

a database within an HIS containing unique patient identification codes for all the patients in a healthcare system

21
Q

EMPI

A

Enterprise Master Patient Index

  • used when there are multiple systems each with its own MPI
  • –uses query and response
  • –local registration system uses EMPI to determine if patient already exists in system
22
Q

Medication Reconcilitation

A

Prevents errors by comparing medications orders to medications patient has been taking

  • –done at all transition: ADT
  • –avoids medication errors like omissions of medications and duplicate medications
23
Q

EMR

A

Electronic Medical Record

-a digital patient record used within a single care setting or environment

24
Q

EHR

A

Electronic Health Record

-a digital patient record that can be used across more than one healthcare organization

25
Q

Lifelong patient record

A

a health record that is with the patient for life

26
Q

PHR

A

Electronic or digital personal health record

-this may contain the information a person wishes to maintain for private use without the information being accessible to any HIS

27
Q

iEHR

A

both the patient and doctor have access to the patient record. Also known as a hybird.

28
Q

bio-surveillance

A

Public health experts who track communicable diseases through EHRs

29
Q

DRG

A

Diagnostic-related group (DRG) coding
–DRG coding modules assist medical record and other personnel to properly categorize a diagnosis that a patient has so that the organization can get reimbursed from the insurance companies or other payers.

30
Q

POE

A

Provider (or physician) order entry (POE)

  • providers directly enter orders for medication and often other tests or services into the POE system
  • also know as computerized provider (or physician) order entry (CPOE)
  • basic POE enables legible, standardized, complete orders this markedly reduces to eliminates errors due to poor handwriting, ambiguous abbreviations, or incomplete orders.
  • more sophisticated POE
  • -performs drug allergy checks, drug-laboratory value checks, drug-drug interaction checks, and so on which reduces not only medical errors of commission but also of omission.
31
Q

Clinical docmentation

A
  • allows clinicians to document or chart information about the patient usually immediately following an encounter
  • can include history and physical, nursing shift assessment, respiratory care assessment patient plans of care etc.
32
Q

CDM

A

Charge Description Management

EHRC (10 decks)

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