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Electronic Health Record (EHR) An electronic record of health-
related information on an individual that conforms to nationally
recognized interoperability standards and that can be created,
managed, and consulted by authorized clinicians and staff across more
than one healthcare organization
Centers for Medicare and Medicaid Services (CMS) a federal agency
within the U.S. Department of Health and Human Services that is
responsible for Medicare and Medicaid, among many other
responsibilities.
Medical Record Number (MRN) a unique number assigned to each
patient seen by a facility or office
minimum necessary concept Protecting private health information
by limiting access based on need.
Notice of Privacy Practices (NPP) a document that is required by
law to inform the patient how the organization will use their healthcare
information.
, Physical Safeguard physical method, policy, or procedure to protect
stored data and software from threats, natural or environmental
hazard, and unauthorized invasion.
Physician Query A request that a provider add documentation to
the EHR to clarify a diagnosis or procedure that has been performed.
practice management system a system that stores information on
revenue cycle processes (appointments, registration, scheduling, health
information management, billing, and coding)
Protected Health Information (PHI) health information that is
specific to a patient
clinical decision support system a program designed to prompt
providers with clinical decisions
Clinical Documentation Improvement (CDI) a process of reviewing
clinical documentation to ensure that it accurately reflects and supports
CPT and ICD-10-CM codes submitted with claims for payment
Compliance program internal policies designed to prevent claim
errors, fraud, and abuse.