Electronic Medical Records Terminology
Health I.T. Common Terms and Definitions
Ambulatory
- Outpatient, or medical services that are provided in a non-hospital setting.
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- ASP (or web-hosted EMR software) is hosted outside of the practice/facility - in a secure data center provided by the software vendor. Client/Server systems are housed on site at the practice/facility, and requires the practice to maintain server equipment and security. There are a variety of aspects when weighing the pros and cons of a web-based EMR and a client/server system - see our detailed discussion of web-based EMR software vs. Client/Server EMR Software.
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- Intermediary service that connects hospitals and physicians payers (insurance companies, HMOs, Medicare, Medicaid). MDS uses the largest clearinghouse in the United States - the McKesson Clearinghouse, or RelayHealth to process claims.
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- Documentation of patient encounter at the point-of-care (i.e. in the exam room). This term is interchangeable with EMR/Electronic Medical Record.
Electronic Health Record / EHR
- How the patient information is captured and exchanged on a regional (or nationwide in the future) level. Interoperability is key to any electronic health record system. However, in practice EHR is often used interchangeably with EMR or Electronic Medical Record to describe clinical software systems.
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Electronic Medical Record / EMR Software
- The software application or the tool used to capture patient encounters, a micro view (like in a specific setting or clinic)
eRx / Electronic Prescribing
- The paperless, electronic transmission of the prescription from the provider or hospital to the pharmacy
Exam Template / EMR Template / Specialty Template
- A predefined model for documenting a specific type of patient encounter or chief complaint
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- Ambulatory electronic health record developer
Healthcare Information Technology / Healthcare I.T. / HIT / Health I.T.
- Healthcare information systems, software, and technologies that work together to exchange information on a systemwide level.
Hospital Information Systems / HIS
- The systems, software, equipment, and technologies used to manage the financial and clinical information within a hospital
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- Integrated systems operate on the same database and usually developed by a single vendor. Interfaced systems often operate on disparate databases and/or architectures and require an interface to communicate and exchange information. A detailed discussion in available in the EMR Software Guide.
Interoperability
- A common set of standards and language that enable disparate software developed by disparate electronic health records vendors to share patient records and information.
Medical Assistant (M.A.)
- Administrative medical assistants are front-office staff, and clinical medical assistants assist licensed clinicians with patient care in the back office.
Medical Back Office Staff
- Clinical support staff, such as Medical Assistants (MA) and Registered Nurses (RN)
Medical Front Office Staff
- Non-clinical administrative support staff. Possibly schedulers, reception, billers, and check out support staff.
PACS
- Picture archiving in medical imaging (radiology)
Personal Health Record / PHR
- A single source of an individual's medical history, maintained and updated by the patient.
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- Medical billing, patient scheduling, and demographics - deals with the day to day functions of an ambulatory medical practice
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- Greenway Medical Technologies' flagship electronic health record product. Comprised of medical practice management and clinical charting functionality.
Tablet PC
- Notebook computer that practitioners used to chart at the point-of-care
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EMR Clinical Charting Software Definitions
Chief Complaint / CC
- Patient's primary complaint
History of Present Illness / HPI
- A chronological order of the symptoms expressed by the patient
Physical Exam / PE
- Physical Exam
PFSH
- Past medical, family, and social history
Review of Symptoms / ROS
- Practitioner reviews 11 systems of the body- general; skin/breast; eyes, ears, nose, mouth, throat; cardiovascular; respiratory; gastrointestinal; genitourinary; muskuloskeletal; neurologic/psychiatric; allergic/immunologic/lymphatic/endocrine.
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