EHR study guide

Active patient One who saw the physician in the last 3 years ICD-10-PCS The format consists of 7 digit codes with the letters a-h, j-n, p-z;replaces vol 3 of the ICD-9-CM Standards Set of commonly agreed-on specifications Unified medical language system (UMLS) Reference database of medical vocabularies Clinical templates Structured progress notes that document patient encounters in an EHR Electronic health record Computerized lifelong health care record with data from all sources Factors in medical errors Poor handwriting; mislabled lab specimens, misfiled records Health information Technology (HIT) Use of technology to manage patient health care information Interoperable System that can exchange information and use the information in a meaningful way Network Equipment that enables computers to exchange information electronically Personal health records (PHR) Individuals comprehensive record of health information; the individual manages the information Electronic medical record (EMR) Computerized record of one physician's encounters with a patient over time Providers who do not adopt EHR system by 2014 Will be subject to financial penalties Business associate Entity that works under a contract for a covered entity and is therefore subject to the covered entities HIPAA policy and procedures Covered entity Organization that processes health information and performs electronic