C468 WGU Information Management
International Classification of Disease (ICD-9/ICD-10) Ans- System for classification of
surgical, diagnostic, and therapeutic procedures.
Electronic Signatures in Global and National Commerce Act (ESIGN) Ans- Legislation
that gives electronic signatures the same legal status as hand-written signatures.
Electronic health record (EHR) Ans- Digital version of patient data found in traditional
paper records. Increasingly used to refer to a longitudinal record ideally of all healthcare
encounters.
Data mining Ans- Technique that looks for hidden patterns and relationships in large
groups of data using software.
Data exchange standards Ans- Set of agreed-on rules that permit the uniform capture
and exchange of data between information systems from different vendors and between
different healthcare providers.
Database administrator (DBA) Ans- Person responsible for overseeing all activities
related to maintaining a database and optimizing its use.
Current Procedural Terminology (CPT) Ans- Classification system that lists medical
services and procedures performed by physicians and is used for physician billing and
payer reimbursement.
Continuity of care document (CCD) Ans- Record comprised of contributions from many
types of caregivers, with each providing a summary of care provided for the purpose of
improved continuity of care when clients move between various points of care.
Computerized physician (or provider/prescriber) order entry (CPOE) Ans- Process by
which the physician or provider directly enters orders for patient care into a hospital
information system.
Computer-based training (CBT) Ans- Educational format using the computer that is
widely used to train persons to use specific computer applications.
Computer-based patient record (CPR) Ans- Automated patient record designed to
enhance and support patient care through availability of complete and accurate data as
well as bodies of knowledge and other aids to care providers.
Community Health Information Network (CHIN) Ans- Organization that electronically
links providers; payers; and purchasers of care for the exchange of financial, clinical,
, and administrative information via a wide area network in a particular geographic area.
Precursor to RHIOs.
Commission on Accreditation of Rehabilitation Facilities (CARF) Ans- Healthcare
accrediting body with a focus on the improvement of rehabilitative services to people
with disabilities and others in need of rehabilitation.
Clinical information systems (CIS) Ans- Large computerized database management
systems used to access the patient data that are needed to plan, implement, and
evaluate care. May also be known as patient care information systems.
Clinical Care Classification System (CCC) Ans- Nursing classification designed to
document the six steps of the nursing process across the care continuum. Consists of
two interconnected terminologies—the CCC of Nursing Diagnosis and Outcomes and
the CCC of Nursing Interventions.
Chief privacy officer (CPO) Ans- Individual responsible for the protection of personal
health information of patients as required by federal law.
Chief information officer (CIO) Ans- Person responsible for strategic planning, policy
development, budgeting, information security, recruitment and retention of information
services staff, and overall management of the enterprise's information systems.
computer-related positions.
Barcode medication administration (BCMA) Ans- Process or system used to ensure that
the correct patient receives the correct medication in the correct dosage via the correct
route and at the correct time. Patients and drugs both have barcode identification
codes.
American Recovery and Reinvestment Act of 2009 (ARRA) Ans- Legislation that
included provisions for health information technology and funding for the Office of the
National Coordinator of Health Information Technology (ONCHIT).
Logical Observation Identifiers, Names, and Codes (LOINC) Ans- Terminology that
includes laboratory and clinical observations.
Medicare Improvements for Patients and Providers Act (MIPPA) Ans- Legislation that
called for financial incentives for e-prescribing.
NANDA International (NANDA-I) Ans- Terminology recognized by the American Nurses
Association. Represents Nursing Diagnoses as data elements within SNOMED CT.
National Health Information Network (NHIN) Ans- Office of the National Coordinator
(ONC) for Health Information Technology (HIT) initiative to provide the standards,
services, and policies that enable secure health information exchange (HIE) over the
Internet.
International Classification of Disease (ICD-9/ICD-10) Ans- System for classification of
surgical, diagnostic, and therapeutic procedures.
Electronic Signatures in Global and National Commerce Act (ESIGN) Ans- Legislation
that gives electronic signatures the same legal status as hand-written signatures.
Electronic health record (EHR) Ans- Digital version of patient data found in traditional
paper records. Increasingly used to refer to a longitudinal record ideally of all healthcare
encounters.
Data mining Ans- Technique that looks for hidden patterns and relationships in large
groups of data using software.
Data exchange standards Ans- Set of agreed-on rules that permit the uniform capture
and exchange of data between information systems from different vendors and between
different healthcare providers.
Database administrator (DBA) Ans- Person responsible for overseeing all activities
related to maintaining a database and optimizing its use.
Current Procedural Terminology (CPT) Ans- Classification system that lists medical
services and procedures performed by physicians and is used for physician billing and
payer reimbursement.
Continuity of care document (CCD) Ans- Record comprised of contributions from many
types of caregivers, with each providing a summary of care provided for the purpose of
improved continuity of care when clients move between various points of care.
Computerized physician (or provider/prescriber) order entry (CPOE) Ans- Process by
which the physician or provider directly enters orders for patient care into a hospital
information system.
Computer-based training (CBT) Ans- Educational format using the computer that is
widely used to train persons to use specific computer applications.
Computer-based patient record (CPR) Ans- Automated patient record designed to
enhance and support patient care through availability of complete and accurate data as
well as bodies of knowledge and other aids to care providers.
Community Health Information Network (CHIN) Ans- Organization that electronically
links providers; payers; and purchasers of care for the exchange of financial, clinical,
, and administrative information via a wide area network in a particular geographic area.
Precursor to RHIOs.
Commission on Accreditation of Rehabilitation Facilities (CARF) Ans- Healthcare
accrediting body with a focus on the improvement of rehabilitative services to people
with disabilities and others in need of rehabilitation.
Clinical information systems (CIS) Ans- Large computerized database management
systems used to access the patient data that are needed to plan, implement, and
evaluate care. May also be known as patient care information systems.
Clinical Care Classification System (CCC) Ans- Nursing classification designed to
document the six steps of the nursing process across the care continuum. Consists of
two interconnected terminologies—the CCC of Nursing Diagnosis and Outcomes and
the CCC of Nursing Interventions.
Chief privacy officer (CPO) Ans- Individual responsible for the protection of personal
health information of patients as required by federal law.
Chief information officer (CIO) Ans- Person responsible for strategic planning, policy
development, budgeting, information security, recruitment and retention of information
services staff, and overall management of the enterprise's information systems.
computer-related positions.
Barcode medication administration (BCMA) Ans- Process or system used to ensure that
the correct patient receives the correct medication in the correct dosage via the correct
route and at the correct time. Patients and drugs both have barcode identification
codes.
American Recovery and Reinvestment Act of 2009 (ARRA) Ans- Legislation that
included provisions for health information technology and funding for the Office of the
National Coordinator of Health Information Technology (ONCHIT).
Logical Observation Identifiers, Names, and Codes (LOINC) Ans- Terminology that
includes laboratory and clinical observations.
Medicare Improvements for Patients and Providers Act (MIPPA) Ans- Legislation that
called for financial incentives for e-prescribing.
NANDA International (NANDA-I) Ans- Terminology recognized by the American Nurses
Association. Represents Nursing Diagnoses as data elements within SNOMED CT.
National Health Information Network (NHIN) Ans- Office of the National Coordinator
(ONC) for Health Information Technology (HIT) initiative to provide the standards,
services, and policies that enable secure health information exchange (HIE) over the
Internet.
