Terms Part 4

Question 1

Also called narrative data, can be entered in a free text format by the user, usually by typing

Answer 1

Unstructured Data

Question 2

The lead federal agency spearheading this national effort to improve patient safety and health outcomes

Answer 2

Office of the National Coordinator for HIT (ONC)

Question 3

Programmed clinical decision support designed to assist the user through making an entry appropriately

Answer 3

Computerized provider order entry (CPOE)

Question 4

A core data set, which is the most relevant administrative, demographic, and clinical information about a patient’s healthcare, covering one or more healthcare encounters

Answer 4

Continuity of care record (CCR)

Question 5

A secure method of communication between the healthcare provider and the patient, just the providers, or the provider and payer.

Answer 5

Patient-provider portal

Question 6

A permanent record of significant information listed in chronological order and maintained across time, ideally from birth to death

Answer 6

Longitudinal health record

Question 7

An EHR that has been evaluated by a member of the Office of the National Coordinator-authorized certification bodies (ONC-ACBs) and verified that it meets the criteria set by the meaningful use incentive programs

Answer 7

Certified EHR Technology

Question 8

An electronic or paper health record maintained and updated by individuals that can be used to collect, track, and share past and current information about their health or health of someone in their care

Answer 8

Personal Health Record (PHR)

Question 9

A software that automates many of the medication administration processes in a health care facility

Answer 9

Electronic medication administration record (EMAR)

Question 10

Information systems that capture and feed data into the electronic health record

Answer 10

Source Systems