| A | B |
|---|
| Electronic Health Record (EHR) | created, managed, and consulted by personnel from more than one Hlthcare org. |
| Electronic Medical Record (EMR) | created, gathered, managed, and consulted by personnel within a single Hlthcare org. |
| Interoperable | capability of a system to work with another system |
| Parameters | set of physical properties |
| Personal Health Record (PHR) | managed, shared, and controlled by the individual |
| Prevalent | Generally or widely accepted |
| Adverse Event | injury caused by medical management |
| Authenticated | proved by signature, initials, or computer keystroke |
| Benchmarks | items or factors that serve as standards |
| Circumvent | to manage to get around |
| Contraindications | factors that make a particular treatment or procedure inadvisable |
| Disparities | fundamentally different and often incongruous elements |
| Encrypted | encoded |
| Erroneous | containing or characterized by error or assumption |
| Near Miss | an error is caught or corrected before it affects the patient |
| Nosocomial | originating or taking place in a hospital |
| Potentially Compensable Event (PCE) | adverse occurrence that could result in a financial obligation for a business or organization |
| Quality Assurance (QA) | activities designed to increase the quality of a product or service |
| Sentinel Events | unexpected occurrences involving death or serious physical or psychological injury |
| Standards | models or examples established by authority, custom, or general consent |
| transposed | interchanged |
| Charge Description Master | system to inventory and record services & items provided by hospital |
| Another Name for CDM | Charge Master |
| admission | pt accepted for inpatient services |
| preadmission testing | tests to identify potential medical problems or establish baseline |
| medical necessity | services or procedures that are reasonable and essential to diagnose or treat |
| quality improvement organization | Medicare contractor who reviews cases to assess medical necessity |
| prospective review | review conducted prior to pt's admission |
| concurrent review | ongoing review during hospital stay |
| retrospective review | review conducted after pt discharge |
| admission evaluation protocol | review to determine appropriateness of admitting pt |
| utilization review | evaluate appropriateness of pt care based on pt's condition |
| charge capture | process of gathering billing info & recording on pt's account |
