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Chapter 13 11/06
23 cards·by cball157
HITECH
Health information technology for economic and clinical health, helps financial
incentives
SOAP
Subjective objective assessment and plan
Medical records kept
5-10 years
Terminal digital
Two digit numbers for ID
Problem oriented
ID patient problem and organize the chart by those problems
PMS
Practice management software, form of software found in medical records
NPP
Notice of privacy practices, how med info about you may be used and disclosed
Active records
Patients who have been seen in the past 3 years
Inactive records
Patients who have NOT been seen the past 3 years
Closed records
Patients who actively terminated their contracts
Digital signature
Most secure type because it is encrypted
EMR
Electronic medical record, computerized version of a patients medical history
Digitized signature
Electronic image of a hand written signature
Meaningful use
A set of criteria for how EHRs are used
Token signature
E-signature which the user must click a button and use a PIN or other task to sign
PHR
Personal health record, health info a patient store electronically or on a secure site
Login
User name and password
Collating
Collecting and putting in proper order all records
SOMR
Source oriented medical record, patient info is organized in sections for various purposes
POMR
Problem oriented medical record, ID patient problems and organising charts by that problem
Color coding
Assigning coloring labels to certain key letters
Numeric coding
Organizing records through the use of numbers
Retroactive
*not this!