HIPPA – Health Insurance Portability and Accountability Act (1996)
**It is important to protect patients informations from access of unauthorized people.
In electronic records you must understand; the key words or abbreviations:
1. CPOE – Computerized Physician Order Entry
2. DUR – Drug utilization review
3. DAW – Dispense as written
4. Sx – Symptoms
5. Hx – History
6. CC – Chief complaint
7. Sig – description (instruction for labelling a prescription)
8. E & M – (Evaluation & Management) most commonly used procedure codes
9. CPT – (Current Procedural Terminology) established by AAMA for Procedure Codes
10.ABN – Advance Beneficiary Notice
11.BMI – Body Mass Index
12.SOAP -(Subjective, Objective, Assessment, Plan)
S – chief complain
O – medical assistant note, health care note
A&P – Physician(s)
13.MRI – Medical Record Initiative
14.Px – Physical Exam
15.Dx – Diagnosis
16.Rx – Prescription
17.URI – Upper Respiratory Infection
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