glossary of terms

Glossary of Electronic Health and Medical Records Related Terms

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ADT (Admissions and Discharge Tracking)

The transactions and tracking of admissions, discharges and transfer both internal and external to the site.

ADT (Admissions and Discharge Tracking)

The transactions and tracking of admissions, discharges and transfers both internal and external to the site.

CCD (Continuity of Care Document)

This is a defined form and method of exchanging relevant discharge and admission information that has been developed by HL7. It represents a defined method to support interoperability and to be able to share patient information between disparate EHR systems.

CCHIT (Certification Commission for Health Information Technology)

The Certification Commission is an independent, 501(c)3 nonprofit organization recognized as a certification body for electronic health records. Their mission is to accelerate the adoption of robust, interoperable health information technology by creating a credible, efficient certification process.

CPOE (Computerized Physician Order Entry)

A function or module in the clinical application that allows the providers to order medications, lab tests, clinical procedures, and other types of activities electronically. It creates an environment where order communication is much faster and more accurate.

EHR (Electronic Health Record)

The electronic health record is a more advanced version of an EMR which provides communication with disparate clinical systems and allows for the sharing of medical information electronically. To achieve interoperability disparate EMRs and clinical systems must have common methods of communicating electronically that are safe, secure and with communication and data standards that allow for the sharing to be seamless and accurate.

EMR (Electronic Medical Record)

The electronic medical record is generally considered to be the composite of all medical and personal information collected regarding individual patients and maintained in a single medical setting such as a SNF or physician office. A complete EMR will allow for medical information collection, access on demand and retention for all medical and patient information that is appropriate and required to accomplish the desired patient care and regulatory compliance. The quality of an EMR should be measured and evaluated based on several factors including: ease of use, adaptability and support of good practices and workflow in the care setting, functional efficiency and the quality of information that is captured and available for use within the care setting.

HIPAA (Health Insurance Portability and Accountability Act of 1996)

In the context of HIT, the purpose of this act and its amendments is to provide regulations that protect the privacy and confidentiality of health information.

HITECH (Health Information Technology for Economic and Clinical Health Act)

HITECH is the Health Information Technology for Economic and Clinical Health Act, or the "HITECH Act,” which established programs under Medicare and Medicaid to provide incentive payments for the "meaningful use" of certified electronic health records (EHR) technology. HITECH was enacted through the ARRA.

HL7 Interface (Health Language 7)

Officially Health Level Seven International is the global authority on standards for interoperability of health information technology.


Interoperability describes the electronic sharing of information or actual care related communications between disparate EMRs and EHRs. The communication of information may be directly through EDI or through regional or national data repositories that are designed and managed for this purpose. The regional and national organizations are usually referred to as HIE (health information exchange) or RHIO (regional health information organization). For LTC, the most common examples of interoperability are direct communication between EHR systems and vendor pharmacies, labs and hospitals.

(LTC) Long-Term Care

LTC generally refers to and includes all settings of post acute care but in some instances only refers to licensed SNFs (skilled nursing facilities or nursing facilities), ALF (assisted living facilities) and ILF (independent living facilities). The more global definition for post- acute- care (LTPAC) includes other licensed organizations such as: LTC acute hospitals, sub acute facilities, long term rehab facilities and home health.

(MAR) Medication Administration Record

The medication administration record whether on paper or electronic as an eMAR refers to the functions of medication administration including clinical documentation. This function done correctly assists and supports the administration of the ordered medications to the correct patient, at the proper time and with all desired safeguards for patient safety properly followed.

MDS (The Minimum Data Set)

The Minimum Data Set has been used as the reimbursement and quality reporting mechanism for approximately 20 years in LTC. The current version is 3.0 and version 4.0 is scheduled to become effective October 1, 2013.

OBRA (The Omnibus Reconciliation Act of 1987)

The Omnibus Reconciliation Act of 1987 created many changes for LTC. Specifically, it launched the MDS and PPS as the new standards for reporting and payment for Medicare.

POC (Point of Care)

Point of Care documentation refers to the ability to document and record patient care activities and patient assessments/observations in a timely fashion and at the point of care. Properly designed POC devices, tools and systems are fundamental to supporting the workflow of clinicians to enhance patient care and create operational efficiencies through the use of POC charting. The POC tools and devices may be implemented in many forms including: computer carts, wall mounted computers, and mobile tablet computers. Near to the point of care devices would include hallway mounted computers or kiosks.

RAI (The Resident Assessment Instrument)

The Resident Assessment Instrument is the extensive set of rules and interpretations to be employed in connection with completing and using the MDS for reimbursement and quality indicators.

RUG (Resource Utilization Group)

Is the defined set of conditions or assessments that determine the reimbursement rates under Medicare Part A and other coverages.

SaaS (Software as as Service)

Software as a Service is generally defined as making the functions of a software system available to a customer through the Internet and with remote hosting of the system. Additionally, not having the application software and mass database storage devices being maintained or owned by the customer is considered part of the services to be offered. The benefits to the customer of SaaS are many, but most importantly the benefits include a lower cost of acquiring the software’s features and functions, a lower cost to manage and maintain the system and database environment and reduced complexity and staffing in the customer’s IT and IS organization.

Structured Progress Notes

Progress notes using preformatted clinical phrases, along with clinical pathways and drill down to the desired level of clinical detail allows for complete clinical documentation and efficiency of entry. This method of clinical documentation also allows for standardized nomenclature which supports interoperability directly when the sharing of information is based on standard data formats and nomenclature.

TAR (Treatment Administration Record)

Similar to the MAR except used for treatments and other patient care activities. The treatment administration record whether on paper or electronic as an eTAR refers to the functions of treatment administration including clinical documentation. This function done correctly assists and supports the administration of the ordered treatments to the correct patient, at the proper time and with all desired safeguards for patient safety properly followed. Wound care and other special treatments can be fully and correctly documented.