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