Definition of Terms
Technology today has revolutionized the health care realm, as technology evolves so does the environment promoting quality care for that in need. This presentation will explain multiple abbreviations needed to translate and describe AMR, CMR, CMS, along with CMS – 1500, and CPT. Also, explore the meaning of DRG, EPR, HL7, ICD – 9 codes, and UB – 92. MAR
Medication administration record is a system put in place to document the administration of medications order verbally or written by the patient’s physician to prove and organize that a medication was given properly to a patient. Other information documented is allergies and is the responsibility of the registered nurse (RN) or Licensed practical nurse (LPN) (Wager, Lee, Glaser, & Burns, 2009). CMR
Computerized Medical Record (CMR) is an electronic information system and keeps records of each individual patient’s health. According to University of Phoenix eBook collection, “Electronic medical record is an electronic record of health related information on an individual that can be created, gathered, managed, and consulted by authorized clinicians and staff within one health care organization” (Wager et al., 2009, Chapter 1). CMS
Centers for Medicare and Medicaid Services (CMS), is clinical indicators focused on improving clinical outcomes. CMS is concentrated on physicians, nursing homes, long - term care facilities, home care, and hospitals. The information obtained can be compared to other hospitals and target locations, medical conditions, outcomes, surveys, and payment information. Giving administrators and researcher’s valuable information directed toward positive or negative outcomes (Wager, Lee, Glaser, & Burns, 2009). CMS-1500
This claim form was adopted by the federal government, created by the American Medical Association (AMA), and maintained by the National Uniform Claim Committee (NUCC). This form has become the standard for noninstitutional provider claims, such as...
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