| A | B |
|---|
| Patient Record | A comprehensive collection of an individual's medical information. |
| Medical Information | Information contained in a patient record from sources such as demographics, history, diagnosis, treatments, medications, test results, and imaging. |
| Demographic Information | Details about the patient's race, sex, age, and address. |
| Medical History | Information composed of reports from providers such as family physicians, allied healthcare providers, hospitals, and specialists. |
| Diagnosis Information | Past and current diagnosis information from a variety of sources. |
| Treatment Information | Information about treatments provided to or planned for a patient. |
| Medication Information | Information about medications associated with a patient's care. |
| Test Results | Results of diagnostic tests included in the patient record. |
| Medical Imaging | Imaging information that may be included in the patient record. |
| Clinical Decision-Making | Use of the patient record to support informed decisions about patient care. |
| Accurate Diagnosis | Correct identification of a patient condition supported by information in the patient record. |
| Treatment Planning | Planning appropriate care using information in the patient record. |
| Continuity of Care | Ongoing, coordinated care across different healthcare settings supported by the patient record. |
| Patient Safety | Protection of patients by reducing medical errors and improving medical management. |
| Population Health Management | Use of patient health records to support understanding and management of health across populations. |
| Exchange of Health Information | Efficient sharing of health information between healthcare organizations. |
| Healthcare Documentation | Entries and documents in the health record that must meet legal and professional requirements. |
| Professional Requirements | Healthcare documentation requirements set by professional standards and healthcare facility statutes. |
| Legal Requirements | Requirements that may govern when and how entries are made and what documents must be included in a health record. |
| Incident and Occurrence Reports | Documents generated for internal risk and quality purposes that should not be placed or referenced in the health record when not related to patient care. |
| Internal Risk and Quality Purposes | Internal organizational purposes for documents such as incident and occurrence reports, rather than patient care. |
| Patient Care | Care-related activity; documents not related to patient care should not be considered part of the health record. |
| Facility-Specific Policies | Policies and procedures developed by healthcare facilities to define the contents and management of health records. |
| Documentation Standards | Standards that support consistency, accuracy, and interoperability of health records across systems and providers. |
| Data Standards | Standards that ensure all pertinent information is captured in the patient record regardless of format. |
| Paper-Based Patient Record | A patient record maintained primarily in paper format. |
| Hybrid Patient Record | A patient record using both paper and electronic formats. |
| Paperless Patient Record | A patient record maintained completely without paper. |
| Data Entry | The method used to enter information into a patient record. |
| Data Types | Categories or forms of data chosen as part of documentation standards. |
| Presenting Information | How health information is displayed or communicated as part of documentation practices. |
| Storing Information | How health information is kept and maintained as part of documentation practices. |
| Communicating Information | How health information is shared or transmitted as part of documentation practices. |
| Master Patient Index (MPI) | A database used by an organization to assign unique patient identifiers and maintain current and accurate demographic and medical information. |
| Unique Patient Identifier | A unique identifier assigned to a patient, often in the form of a unit number. |
| Enterprise-Wide Master Person Index (EMPI) | A system used across multiple organizations to identify, match, merge, and ensure the accuracy of patient records. |
| Admission | The point when registration and health information systems interact with the EMPI during entry of new patients. |
| Patient Registration | The initial step in healthcare where a patient's demographic and administrative information is collected and entered in the system. |
| Administrative Information | Non-clinical information collected during patient registration for administrative purposes. |
| Downtime Procedures | Procedures established to direct registration and health records staff during computer or communication outages. |
| Computer Outage | A disruption in computer access that requires downtime procedures. |
| Communication Outage | A disruption in communication systems that requires downtime procedures. |
| Redundant Systems | Intentional duplication of core information to improve reliability and operability. |
| Continuity of Patient Care | Continued care supported by access to patient information during technical disruptions. |
| Data Accessibility | Ability to access patient data, including during downtime situations. |
| Critical Information | Important patient information safeguarded against loss during downtime situations. |
| Completeness | A quality of health information indicating that required information is included. |
| Accuracy | A quality of health information indicating that information is correct. |
| Consistency | A quality of health information indicating information is uniform and reliable across records or systems. |
| Timeliness | A quality of health information indicating that entries are made when needed and without undue delay. |
| Integrity | A quality of health information indicating that information remains reliable, complete, and unaltered except through proper processes. |
