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  2. Consolidated Clinical Document Architecture - Wikipedia

    en.wikipedia.org/wiki/Consolidated_Clinical...

    Progress Note - This template represents a patient's clinical status during a hospitalization, outpatient visit, treatment with a LTPAC provider, or other healthcare encounter. [ 14 ] Transfer Summary - The Transfer Summary standardizes critical information for exchange of information between providers of care when a patient moves between ...

  3. Medical billing - Wikipedia

    en.wikipedia.org/wiki/Medical_billing

    While an insured patient typically interacts only with a healthcare provider during a visit, the encounter is part of a three-party system. The first party in this system is the patient. The second is the healthcare provider, a term that encompasses not only physicians but also hospitals, physical therapists, emergency rooms, outpatient ...

  4. Health information management - Wikipedia

    en.wikipedia.org/wiki/Health_information_management

    The patient health record is the primary legal record documenting the health care services provided to a person in any aspect of the health care system. The term includes routine clinical or office records, records of care in any health related setting, preventive care, lifestyle evaluation, research protocols and various clinical databases.

  5. Patient check-in - Wikipedia

    en.wikipedia.org/wiki/Patient_Check-In

    Patient check-in is the process where patients begin their registration with the healthcare facility topically using a clipboard, electronic tablet, touch screen, kiosk, or by other method, sometimes self-service. Patient check-in start as far back as the Roman times when patients would wait for special services in purpose-built hospitals.

  6. Continuity of Care Document - Wikipedia

    en.wikipedia.org/wiki/Continuity_of_Care_Document

    The patient summary contains a core data set of the most relevant administrative, demographic, and clinical information facts about a patient's healthcare, covering one or more healthcare encounters. It provides a means for one healthcare practitioner, system, or setting to aggregate all of the pertinent data about a patient and forward it to ...

  7. Medical record - Wikipedia

    en.wikipedia.org/wiki/Medical_record

    The information contained in the medical record allows health care providers to determine the patient's medical history and provide informed care. The medical record serves as the central repository for planning patient care and documenting communication among patient and health care provider and professionals contributing to the patient's care.

  8. SOAP note - Wikipedia

    en.wikipedia.org/wiki/SOAP_note

    [1] [2] Documenting patient encounters in the medical record is an integral part of practice workflow starting with appointment scheduling, patient check-in and exam, documentation of notes, check-out, rescheduling, and medical billing. [3] Additionally, it serves as a general cognitive framework for physicians to follow as they assess their ...

  9. Health Insurance Portability and Accountability Act - Wikipedia

    en.wikipedia.org/wiki/Health_Insurance...

    EDI Health Care Claim Status Notification (277) is a transaction set that can be used by a healthcare payer or authorized agent to notify a provider, recipient, or authorized agent regarding the status of a health care claim or encounter, or to request additional information from the provider regarding a health care claim or encounter. This ...