Health and medical

26 cards


 
  
Created Dec 17, 2013
by
Carry0309

 

 
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1
ONCHIT (Office of the National Coordinator of Health Information Technology)
 
-Government affiliated -Sets standards for use and compatibility of EHR software
2
Hybird
 
Merging from paper to electronic records
3
IOM
 
Institute of Medicine outlines the 8 core functions of EHR
4
Acute Care
 
Most often refers to a haspital, treats pt with urgent problems that cannot be handled
5
Ambulatory Care
 
Refers to treatment without admission to hospital
6
SNOMED-CT
 
Clinical vocabulary designed to encompass all terms used in medicine.
7
LOINC
 
Terms and codes used for electronic exchange of lab results and clinical observations
8
UMLS
 
Thesaurus database of medical terms
9
CPOE (computerized physician order entry)
 
-Ordering of tests & medications via automated format -Reduces errors, delays and duplication
10
Vital signs
 
Measurements of the pt temperature, respirations, pulse and blood pressure
11
Chief Complaint (CC)
 
The PT stated primary reason for seeking treatment
12
Progress Notes
 
Documentation of the care deliered to a pt along with necessary info regarding ther diagnosis...
13
Past Medical History
 
Information regarding the pt past medical problems, conditions or surgeries
14
Family History
 
Information regarding the medical problems of the pt family
15
Social History
 
Information regarding the pt lifestyle such as smoking and drinking habits, relationship status...
16
Allergies
 
A list of the pt allergies as well as their reactions to each one
17
Medication List
 
Information regarding the dosage and freuency of the pt medications
18
HPI (history of present illness)
 
A compilation of information regarding all aspects of the pt present illness
19
ROS (Review of symptoms)
 
An inventory of body systems in which the pt reports signs or symptoms he or she is currently...
20
Diagnosis and Assessment
 
The physicians conclusion regarding the cause of the pt problem
21
Plan and Treatment
 
The physicians recommended plan of action to cure or manage the pt condition
22
CCHIT (Certification Commission for Healthcare Information Technology)
 
-Independent, voluntary and private sector -Goal accelerate and adoption of health info technology
23
Electronic transcription
 
Data entry using handwriting or voice recognition or other digital means.
24
Interoperability
 
The ability of electronic systems to share information in compatible formats.
25
PT statement
 
Document that contains the amount owed and other billing details
26
CMS 1500
 
A standard form that speeds the claims process for doctors and suppliers

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