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Electronic Health Record Chapter 2

Is a file containing the documentation of a patient's medical history and related information

Medical Record

Superbill

Routing Slip

Encounter Form

Can provide access to the latest medical research on approved medical websites to help medical decision making

Clinical decision support

Documentation Support

Electronic Communication

Administration and Reporting

Is a visit between a patient and a medical professional

Encounter

Service

EHR

Phone consultation

Evaluation and management is abbreviated as

E/M

E&M

E-M

When a provider ask questions about the functions of each body system, it is considered a

Review of systems

Past Medical History

Social History

Family Medical History

Are prepared during a patient's final visit for a particular treatment plan or hospitalization

Discharge Summaries

Progress Reports

End-Of-Care Notes

Closed-Status Reports

Individually identifiable health information transmitted or maintained by electronic media is called

PHI

EHR

PHR

HIPAA

Medical Records are what type of documents

Legal

Unofficial

Not Legal

Unnecessary

Federal agency that runs Medicare, Medicaid, clinical laboratories, and other government health programs

CMS

HITECH

HIPAA

REC

Utilization of certified EHR technology to improve quality, efficiently and patient safety

Meaningful Use

PHR

HIT

None

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