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Tip: Expand your EHR vocabulary with six new definitions

EHR Connection, February 4, 2008

New endeavors often require learning a new "language."

If an EHR system is on the horizon at your facility, that's exactly what you and your colleagues will be doing. The following definitions will help ease the transition and facilitate communication as you adjust to the new technology:

• Audit trail function: a reporting function that monitors access to the EHR and movement of paper charts where they are still in use. The information system should be able to track and monitor access of other activity by certain individuals or events. Tracking may include detailed information about the activity, such as user name, location, date, time, specific documentation accessed, and whether reports were printed.
• Cut: the electronic removal or deletion of text from a source document.
• Decision support: electronic functionality built into the EHR to support decisions and knowledgeable management. For example, order entry systems include alerts and prompts to facilitate awareness of drug interactions. Decision support systems are not considered part of the legal health record.
• Document imaging: the process of electronically scanning paper documents into an electronic system for later retrieval.
• Healthcare Information and Management Systems Society (HIMSS): a membership organization whose goal is the betterment of healthcare through the optimal use of healthcare information technology and management systems.
• Hybrid health record: a combination of at least two different media in an organization's health record, such as partially electronic and partially paper. Employees must manage both.

This tip is brought to you by The Legal Health Record Companion: A case study approach published by HCPro, Inc. Look for more definitions in the February 11 issue of EHR Connection.

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