INTRODUCTION ACMA TEST |A+ Graded!!
Key Terminology for Electronic Record Keeping
Electronic Medical Records (EMR) are computerized records of one physician's encounter with a
patient over time. The EMR reflects treatment of a patient by one physician.
Electronic Health Record (EHR) reflects the data from all sources that have treated the individual.
Personal Health Record (PHR) are maintained and owned by the patient. The patient makes the
decision whether to share the contents with their physician.
Acute care, most often refers to a hospital, treats patients with urgent problems that cannot be
handled.
Ambulatory care refers to treatment without admission to hospital.
Clinical templates allow doctors to document patient encounters into an EHR on a structured form.
RADT refers to registration, admissions, discharge and transfer
UPI is the unique patient identifier links all clinical observations, tests, procedures, complaints,
evaluations, and diagnoses to the patient.
DATA may be structured or unstructured. Unstructured data could be a dictated report, a written
progress note, or voice files et.al. Structured data is standard templates, bar codes and numeric codes
et. al.
Decision support software is used to access current information about a disease or condition. Used by
physicians.
Voice Recognition software translates what a provider is saying and types those words into text.
Master Patient (person) Index (MPI) is where patients are listed/entered only once and allows for
documentation of each visit.
Button an element of the user interface on which the user can click to execute a command such as
confirm, cancel or exit
Clinical templates allow doctors to document patient encounters into an EHR on a structured form.
Context Specific generated to help the user in a specific context or to carry out a particular task
Key Terminology for Electronic Record Keeping
Electronic Medical Records (EMR) are computerized records of one physician's encounter with a
patient over time. The EMR reflects treatment of a patient by one physician.
Electronic Health Record (EHR) reflects the data from all sources that have treated the individual.
Personal Health Record (PHR) are maintained and owned by the patient. The patient makes the
decision whether to share the contents with their physician.
Acute care, most often refers to a hospital, treats patients with urgent problems that cannot be
handled.
Ambulatory care refers to treatment without admission to hospital.
Clinical templates allow doctors to document patient encounters into an EHR on a structured form.
RADT refers to registration, admissions, discharge and transfer
UPI is the unique patient identifier links all clinical observations, tests, procedures, complaints,
evaluations, and diagnoses to the patient.
DATA may be structured or unstructured. Unstructured data could be a dictated report, a written
progress note, or voice files et.al. Structured data is standard templates, bar codes and numeric codes
et. al.
Decision support software is used to access current information about a disease or condition. Used by
physicians.
Voice Recognition software translates what a provider is saying and types those words into text.
Master Patient (person) Index (MPI) is where patients are listed/entered only once and allows for
documentation of each visit.
Button an element of the user interface on which the user can click to execute a command such as
confirm, cancel or exit
Clinical templates allow doctors to document patient encounters into an EHR on a structured form.
Context Specific generated to help the user in a specific context or to carry out a particular task
