A digital or paper-based record-keeping system used by healthcare providers to document patient medical information, including diagnoses, treatments, medications, and vital signs.
A digital version of a patient’s paper chart, containing medical history, diagnoses, medications, treatment plans, immunization dates, allergies, radiology images, and laboratory test results.
An acronym for Subjective, Objective, Assessment, and Plan. SOAP notes are a structured format used by healthcare professionals to document patient encounters comprehensively.
A system of alphanumeric codes used to classify and code diagnoses, symptoms, and procedures for medical billing, statistical tracking, and epidemiological research.
A standardized system of medical codes used by healthcare providers to report medical, surgical, and diagnostic procedures and services performed in outpatient settings.
Legislation that protects patients’ privacy and security concerning their health information, establishing standards for electronic health transactions and ensuring the confidentiality of medical records.
Any information about a patient’s health status, medical treatment, or payment for healthcare that can be linked to an individual. PHI is protected under HIPAA regulations.
The remote delivery of healthcare services using telecommunications technology, enabling healthcare professionals to evaluate, diagnose, and treat patients at a distance.
A chronological record that documents who accessed a patient’s medical chart, what actions were taken, and when they were performed. Audit trails help ensure the integrity and security of electronic health records and facilitate compliance with regulatory requirements.