Difference between revisions of "Acronyms, Abbreviations & Other Definitions"
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*[[EHR]] – Electronic Health Record, industry term. A patient’s medical record in a digital format. Owned and controlled by the provider.
*E/M Coder – Evaluation and Management Coder
*E/M Coder – Evaluation and Management Coder
*[[EMAR]] - Electronic Medication Administration Record
*[[EMAR]] - Electronic Medication Administration Record
Revision as of 15:45, 9 October 2013
Brief definitions are listed below. If there is more detailed information available or needed about a particular item, then there will be a link either from the acronym or from the real term to a page with that information.
- ABN - Advanced Beneficiary Notice of Noncoverage. See CMS link for additional information.
- ACI - Add Clinical Item
- ACOG - American Congress of Obstetricians and Gynecologists
- ADBR - Application Design and Behavior Resource. A tool provided from Allscripts for configuring and troubleshooting.
- ADM - Allscripts Document Management (formerly known as Scan module)
- ADT - Admission, Discharge, Transfer
- AE-EHR - Allscripts Enterprise EHR
- AE-PM - Allscripts Enterprise Practice Management
- AHIMA - American Health Information Management Association
- AHSVOE - AHS Virtual Object Engine (see AHSVOEService)
- AMA - American Medical Association
- ANR - Available Next Release - Allscripts term referring to functionality that exists in a future version
- AOE - Ask at Order Entry
- ARRA - American Recovery and Reinvestment Act of 2009
- BAW - Build Activity Workbook . Allscripts terminology; is a workbook provided to clients to assist and organize v11 data collection and build activities.
- Best Practice - Best practice is a term that refers to a process that, when used, produces optimal results.
- CAH - Critical Access Hospital
- CCD - Continuity of Care Document
- CCHIT - Certification Commission for Health Information Technology- is an independent, not-for-profit group that certifies electronic health records.
- CDA - Clinical Document Architecture
- CCF - Client Confirmation Form
- CCR - Continuity of Care Record
- CDT - Clinical Desktop
- CED - Clinical Exchange Document
- CEHRT - Certified EHR Technology
- CG CareGuides - A large set of templates created by Allscripts for Touchworks for common medical conditions including diseases, injuries and health maintenance.
- CIS - Clinical Information System, industry word. Generic term used to describe the software programs designed to capture manage and analyze health care data.
- CLR - Common Language Runtime. It is Microsoft's implementation of the Common Language Infrastructure (CLI) standard, which defines an execution environment for program code. http://en.wikipedia.org/wiki/Common_Language_Runtime
- CMS - Centers for Medicare and Medicaid. Their home page http://www.cms.hhs.gov/ and more information http://en.wikipedia.org/wiki/Centers_for_Medicare_and_Medicaid_Services
- CMT - Content Management Tool. This is a content management tool created by Allscripts and accessed very similarly to SSMT. Its primary function is to migrate more complex data elements and build items such as Note Forms and resultable items.
- CPOE - Computerized Physician Order Entry, industry term. The electronic entry by a physician of treatment instructions for patients under his or her care. These orders are communicated over a computer network to medical staff or departments responsible for fulfilling the order. http://en.wikipedia.org/wiki/CPOE
- CPT4 - Current Procedural Terminology, 4th Edition, medical term. A standardized set of codes established by the American Medical Association to identify medical procedures performed and for billing purposes.
- DEA - Drug Enforcement Agency
- DUR - Drug Utilization Review-
- EHR – Electronic Health Record, industry term. A patient’s medical record in a digital format. Owned and controlled by the provider.
- E/M Coder – Evaluation and Management Coder. Provides decision support for the clinician, assisting in their review of the clinical note when determining the level of service for the encounter.
- EMAR - Electronic Medication Administration Record
- EMR – Electronic Medical Record, industry term. A patient’s medical record in a digital format.
- EP - Eligible Provider. This is a Meaningful Use term and refers to a provider who is eligible to participate in the Medicaid or Medicare reimbursement programs.
- ETL - Extract, Transform, Load
- FQDN – Fully Qualified Domain Name, computer/networking term. Used to describe the combination of a device's host-name and domain name (ex. AHSWEB.Example.com).
- FTP – File Transfer Protocol, computer term. A network protocol for transferring files over the internet. http://en.wikipedia.org/wiki/Ftp
- FoS - Term commonly used to a Result Document, but can relate to any Note/Document in Enterprise EHR that is set to 'Finalize on Save.'
- FYI - The FYI button is found on the Patient Banner and is used to place notes related to a patient the way a sticky note could be used on a chart. When there is text/data in the FYI field the button is yellow.
- GUI - Graphical User Interface
- HCC - Hierarchical Condition Categories
- HCPCS- Healthcare Procedural Coding System. (Coders refer to it as "Hix Pix".)
- HEDIS - The Healthcare Effectiveness Data and Information Set-Tool used to measure performance on important dimensions of care and services.
- HF - Hot Fix version
- HIE - Health Information Exchange
- HIMMS - Healthcare Information and Management Systems Society
- HIPAA – Health Insurance Portability and Accountability Act, legal and medical term. Relates to the legal act of 1996.
- HIT - Health Information Technology-used to improve the efficiency and quality of health care that patients receive. System where medical professionals store information usually contained in a patients chart on a computer, rather than on paper
- HL7 - Health Level Seven - a standard development organization that supports the development and maintenance of a health data exchange protocol.
- HMP – Health Management Plan, Allscripts Term – this is a component of the Clinical Desktop within Touchworks. It is a workspace for reviewing current orders, meds, order reminders, alerts and results for active problems
- HTB – Horizontal Tool Bar; the menu bar that appears horizontally across the screen.
- Hx - is used in medical shorthand to mean "history"
- ICD-9 - International Statistical Classification of Diseases and Related Health Problems
- ICD-10 - This code set is scheduled to replace ICD-9-CM, our current U.S. diagnostic code set, on Oct. 1, 2013.
- IHE - Integrating the Healthcare Enterprise
- IPA - Independent Practice Association-consists of a network of physicians in a region or community who agree to participate in an association to contract with health maintenance organizations, other managed care plans, and also vendors for the benefit of each of the physicians in the IPA.
- ISO - International Organization for Standardization
- JCAHO - Joint Commission on Accreditation of Healthcare Organizations (In 2007, formally changed their name to JC)
- JC - Joint Commission
- KB – Allscripts Knowledge Base, Allscripts term – the knowledge base is an online resource created by Allscripts as a resource tool to support Touchworks users.
- KIL – Known Issues List - furnished by Allscripts and is a comprehensive list of issues that are know to occur as a result of upgrading to a newer version of Enterprise EHR.
- KPI - Key Performance Indicator; business term. Can include common measures and statistics aggregated from the EHR in order to assess compliance, meaningful use, or work flow consistency.
- LAN - Local Area Network
- LIS - Laboratory Information System. A general term often used to reference an internal or external laboratory system.
- LMRP - Local Medical Review Policy
- MAPI - Acronym for clinical data (Meds, Allergies, Problems, Immunizations)
- MAR - Medication Administration Record
- MDM - Medical Document Management
- MPI - Master Patient Index - Used Interchangeably with Patient Master Index (PMI). An index that contains a unique identifier for every patient in the enterprise
- MSO - Managed Services Organization or Medical Services Organization
- MU - Meaningful Use 
- NABP # - National Association of Boards of Pharmacy Number - Each licensed pharmacy in the United States is assigned a unique seven-digit number by the National Council for Prescription Drug Programs (NCPDP), in cooperation with the National Association of Boards of Pharmacy. The purpose of this system is to enable a pharmacy to identify itself to all third-party processors by one standard number.
- NAW - Note Authoring Workspace
- NCQA - National Committee for Quality Assurance
- NDC - National Drug Code
- NPI - National Provider Identifier
- OBR - Observation Request Segment
- OCD – Orderable Concept Dictionary, Allscripts term – This is a dictionary that comes with Touchworks that is a consistent dictionary of orders and results. This was created to deal with differences in medical terminology in different locations and with different vendors.
- OID – Orderable Item Dictionary, Allscripts term – This is the dictionary of things that can be ordered, received or recorded as results. These terms can vary from hospital to hospital, and are therefore mapped to items in the orderable concept dictionary for consistency.
- ORM - Observation Result Messages
- ORU - Observation Result Unsolicited
- PACS – Picture Archiving and Communication System – used to exchange medical images over a network (X-rays, ultrasound etc.)
- PAT – Physician Administration tool
- PBM - Pharmacy Benefit Manager
- PCMH - Patient Centered Medical Home- NCQA's program for improving primary care
- PCP - Primary Care Provider
- PHI - Personally Identifiable Health Information
- PHR – Personal Health Record –owned and controlled by the patient
- PM - Practice Management
- PMH - Past Medical History
- PMS - Practice Management System
- PMT - Problem Mapping Tool
- PQRI - Physician Quality Reporting Initiative-for 2009 consists of 153 quality measures and 7 measure groups
- PSH - Past Surgical History
- REC - Regional Extension Center: an organization that has received funding under the Health Information Technology for Economic and Clinical Health Act (HITECH Act) to assist health care providers with the selection and implementation of electronic health record (EHR) technology.
- RIL - Resolved Issues List - furnished by Allscripts and is a comprehensive list of issues that are resolved as a result of upgrading to a newer version of Enterprise EHR.
- RIS - Radiology Information System
- RLS - Record Locator Service - An index that lets clinicians find out where the patient information they seek is stored so that they can request it directly from its source.
- ROI – Return on Investment or Release of Information, when used by medical records staff
- RPL - Requested Performing Location
- RTI - Real Time Intervention or can refer to Allscripts' now retired ticket/support management system. It is common for KB articles and documentation to contain references to the RTI ticket numbers.
- RVU - Relative Value Units
- RX+ – a module of Touchworks that allows clinical staff to manage their patients' medications, as well as provides tools for prescribing utilizing DUR checking and plan-specific formularies
- SES - System Environment Specification - Allscripts term
- SIG – From the Latin “Signa”, meaning to write. This is a medical abbreviation used when writing prescriptions meant to mean “write the following instructions on the label”
- SIU - Schedule Information Unsolicited (message)
- SQL - Structured Query Language; technical term. The primary DBMS and programming language for Enterprise EHR.
- SSMT – Starter Set Migration Tool – this is a tool used to move items from test to live
- TCP/IP - Transfer Communication Protocol/Internet Protocol. http://en.wikipedia.org/wiki/TCP/IP
- TES – Transaction Editing Software
- TIU - Text Input Utility - this is the Word integrated transcription tool for typing and submitted transcriptions in the EHR
- TW – Touchworks
- TWPM – Touchworks Practice Management
- Tx - Medical shorthand for treatment
- VPN – Virtual Private Network
- VTB – Vertical Tool Bar – The tool Bar that runs up and down the screen, usually on the left hand side
- WAD - Working As Designed
- XML - Extensible Markup Language, a computer term.