Ehrgo Health Information Terminology

Question 1

Abstracting

Answer 1

The process of extracting information from a document to create a brief summary of a patient’s illness, treatment and outcome.

Question 2

Addendum

Answer 2

Note that is added (and attached to) to a completed note after it has been finalized (signed by the author).

Question 3

Authorization

Answer 3

The granting of permission to disclose confidential information. As defined in terms of the HIPAA privacy rule, an individual’s written permission to use or disclose his or her personally identifiable health information for purposes other than treatment, payment or health care operations. (45 C.F.R. § 164.508)

Question 4

Care plan

Answer 4

A standardized written plan for the patient’s care for the health care team to follow.

Question 5

Centers for Medicare & Medicaid Services (CMS

Answer 5

The federal agency within the United States Department of Health and Human Services (HHS) that administers the Medicare, Medicaid, Children’s Health Insurance Program, and the Health Insurance Marketplace. (CMS)

Question 6

Clinical data

Answer 6

Captured during the process of diagnosis and treatment, supports direct patient care and is used for health care reimbursement, planning and research purposes. (Abdelhak)

Question 7

Coded data

Answer 7

Controlled data entered into specific fields in the EHR which enable the retrieval, or data mining, of the entered information. Examples of coded data include ICD diagnostic codes, CPT procedural codes and health factors.

Question 8

Current Procedural Terminology (CPT

Answer 8

): A coding system used to provide uniform language that accurately describes medical, surgical and diagnostic services.

Question 9

Data mining

Answer 9

Aggregating and reporting of data from coded fields within the EHR.

Question 10

Diagnosis

Answer 10

The name for the health problem that you have. Often called a “medical problem” or just simply, “problem.”

Question 11

Diagnosis code

Answer 11

A code describing the principal diagnosis, additional conditions that coexisted at the time of admission, or developed subsequently, and which had an effect on the treatment received or the length of stay. Sometimes referred to as the ICD-10 code.

Question 12

Diagnosis Related Groups (DRG)

Answer 12

A classification system that groups patients according to diagnosis, type of treatment, age and other relevant criteria. Under the prospective payment system, hospitals are paid a set fee for treating patients in a single DRG category, regardless of the actual cost of care for the individual. (CMS)

Question 13

Electronic Health Record (EHR)

Answer 13

Longitudinal patient records that are maintained electronically in a manner that is accessible to caregiver, the patient and others who need access to specific information or to aggregate information to prevent illness and improve future treatment

Question 14

Electronic Medical Record (EMR)

Answer 14

Electronic patient records that are developed by individual health care providers/organizations. EMRs are composed of whole files as opposed to individual data elements. The data from the EMR are the source of data for the electronic health record. (Abdelhak)

Question 15

Encoder

Answer 15

Specialty software used to facilitate the assignment of diagnostic and procedural codes according to the rules of the coding system.

Question 16

Healthcare Provider

Answer 16

A person who is trained and licensed to give health care. Also, a place that is licensed to give health care. Doctors, nurses, and hospitals are examples of health care providers. (Fordney)

Question 17

Health Factor

Answer 17

A type of coded data that captures patient health information for which no standard diagnostic code exists, such as Family History of Alcohol Abuse, Lifetime Non-smoker, No Risk Factors for Hepatitis C, etc

Question 18

Health Informatics (aka: Healthcare Informatics)

Answer 18

): The intersection of information science, medicine, and health care. It deals with the resources, devices, and methods required to optimize the acquisition, storage, retrieval, and use of information in health and biomedicine. (MTU) Health informatics tools include not only computers, but also clinical guidelines, formal medical terminologies, and information and communication systems.

Question 19

Health Information Technology

Answer 19

Broadly defined as the use of information and communication technology in health care.

Question 20

Health Insurance Portability and Accountability Act (HIPAA):

Answer 20

A US law that provides patients with access to their medical records and provides privacy standards to protect patients’ medical records and other health information. (MedicineNet)

Question 21

Inpatient

Answer 21

Health care you receive when you are admitted to a hospital.

Question 22

International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM)

Answer 22

The official system used in the United States prior to 2014 to classify and assign codes to health conditions and related information. The use of standardized codes improves consistency among physicians in recording patient symptoms and diagnoses.

Question 23

International Classification of Diseases, Tenth Revision (ICD-10)

Answer 23

Was created in 1992 as the successor to the previous ICD-9 system. In the United States, an official use of the ICD-10 system began in 2014. It is split into two systems: ICD-10-CM (clinical modification) for diagnostic coding and ICD-10-PCS (procedure coding system) for inpatient hospital procedure coding.

Question 24

Meaningful Use

Answer 24

Meaningful use describes the use of health information technology (HIT) that leads to improvements in healthcare and furthers the goals of information exchange among health care professionals. To become Meaningful Users, health professionals need to demonstrate they’re using certified EHR technology in ways that can be measured in quantity and in quality, such as the recording and tracking of key patient health factors to enable the planning and delivery of timely and effective care. (HealthIT.gov)

Question 25

Medicaid

Answer 25

A joint federal and state program that helps with medical costs for some people with low incomes and limited resources. Medicaid programs vary from state to state, but most health care costs are covered if you qualify for both Medicare and Medicaid.

Question 26

Medical record number

Answer 26

A unique numeric or alphanumeric identifier assigned to each patient’s record upon admission to a healthcare facility. Also referred to as a Health record number.

Question 27

Medical transcription

Answer 27

The conversion of verbal medical reports dictated by healthcare providers into written form for inclusion in patients’ health records.

Question 28

Medicare

Answer 28

The federal health insurance program for: people 65 years of age or older, certain younger people with disabilities, and people with End-Stage Renal Disease (permanent kidney failure with dialysis or a transplant, sometimes called ESRD).

Question 29

National patient safety goals

Answer 29

Set of goals published each year by the Joint Commission (JCAHO) and designed to improve patient safety in specific healthcare areas identified as problematic by the Sentinel Event Advisory Group

Question 30

Outcome

Answer 30

The result of performance (or nonperformance) of a function or process.

Question 31

Outpatient

Answer 31

Medical or surgical care that does not include an overnight hospital stay. Outpatient care is typically provided in ambulatory surgery centers, clinics, doctor’s offices, urgent care clinics, etc.

Question 32

Patient account number

Answer 32

A number used assigned by a healthcare facility for billing purposes that is unique to a particular episode of care; a new account number is assigned each time the patient receives care or services at the facility.

Question 33

Patient Encounter

Answer 33

CMS defines patient encounters as any encounter (i.e. office visit) where a medical treatment is provided and/or an evaluation and management services are provided. In EHR Go! the patient encounter information is recorded on the Encounters tab and will also display on the Overview.

Question 34

Patient record

Answer 34

Primary source of health data and information for the health care industry. The record can be paper-based, electronic or a combination of both referred to as a hybrid record. It is the legal documentation of care provided to an individual by the medical or health care professionals who practice in the setting.

Question 35

Plan of Care

Answer 35

A doctor or practitioner’s written plan saying what kind of services and care needed for a health problem

Question 36

Policies

Answer 36

Governing principles that describe how a department or an organization is supposed to handle a specific situation.

Question 37

Quality Improvement

Answer 37

Formal approach to the analysis of performance and systematic efforts to improve it.

Question 38

Quality analysis

Answer 38

A review of the health record to determine its completeness and accuracy.

Question 39

Release of Information (ROI)

Answer 39

The process of disclosing patient-identifiable information from the health record to another party. Requires a signed form by the patient allowing the release of their information.

Question 40

Research Data

Answer 40

Collected as part of care or gathered for specific research purposes or clinical trials.

Question 41

Standard

Answer 41

A model or an example established by authority or general consent, or by a rule established by an authority, as a measure of quantity, quality or value.

Question 42

Template

Answer 42

In the EHR, a document with instructions, pre-defined documentation choices, and/or narrative documentation in a format that has not been produced yet.

Question 43

The Joint Commission (TJC):

Answer 43

A nonprofit tax-exempt organization that accredits more than 21,000 health care organizations and programs in the United States. A majority of state governments recognize Joint Commission accreditation as a condition of licensure and the receipt of Medicaid reimbursement. (Joint Commission)

Question 44

Unsigned

Answer 44

Note has not been signed by the author, on paper or electronically.

Question 45

User Class

Answer 45

Classifying an individual user by professional scope of practice; i.e. Nurse, Doctor, Medical Assistant, etc.