Glossary
Consistently use the same set of words, spelling, and capitalization, otherwise what you write will look messy and confusing.
In general, if a feature or product isn’t unique to Commure, such as a blog, then don’t capitalize it. If it’s unique to Commure and marketable as its own product, such as Commure Listrunner, then capitalize it. Edge cases are assessed individually and documented here.
Use American English spelling for all physician-facing content. When in doubt, check the Merriam-Webster dictionary or Stedman's Medical Dictionary for the preferred spelling of specific terms not found in this list.
A
academic medical center
access
accountable care organizations (ACOs)
Groups of healthcare specialists, centers and other providers who render high-quality care to their Medicare patients on a voluntary basis.
accountable health plan
accreditation
ACLS (ACLS)
activities of daily living
activity-based costing (ABC)
An accounting software methodology enabling medical organizations to calculate costs of each case of care provided like hospital, physician, and medication expenses.
acute care
acute disease
adherence
adjudication
admin
This is the Commure user use to manage their platform or app. Example: Log in to your Commure admin.
admission
admission criteria
admission, discharge, and transfer (ADT system)
One of the four types of the hospital business system that tracks patients’ admissions, transfers, and discharges.
advanced practice nurse
against medical advice
allied health personnel
allopathic medicine
alternative medicine
ambulation
ambulatory care
ambulatory ehr systems
Software that is applied in outpatient care facilities and smaller practices allowing physicians to collect specific info about each patient and providing a full-fledged medical picture of their personal health records.
ambulatory medical record (AMR)
A computer system for collecting, managing, and retrieving EHRs in the outpatient setting.
American Academy of Professional Coders (AAPC)
The expert coding training and certification association for medical programmers, billers, compliance and practice managers in the U.S.
American Medical Association
anatomy
ancillary care
ancillary services
app
An abbreviation for application. A software program designed to perform a specific function directly for the user or another app. Apps can be integrated with Commure to enhance functions and features. The Commure App Store has both paid and free apps built by Commure and partners. Example: List your app in the Commure App Store.
appointment
appropriateness
assessment
ATLS (ATLS)
attending
attestation
authorization
autonomy
B
backup call
bathroom privileges (BRP)
bed control
behavioral health care
bench research
beneficence
beneficiary
bidirectional health information exchange (BHIE)
A medical info sharing project that allows for two-way PHI data exchanging between the U.S. Department of Defence and the Veterans Health Administration.
birddog
blood bank
BLS (BLS)
Blue Button
board certified
bolus
brand drug name
business intelligence (BI apps)
Software which supports financial and operational aspects of the healthcare system, including contract negotiations, facility management, measurement of resource utilization, and cost analysis.
C
call schedule
callback number
care plan
care team
case conference
case manager
census
central supply
Certification Commission for Healthcare Information Technology (CCHIT)
A voluntary, private sector organization for certifying health IT products, such as EHRs and the networks over which they interact.
charge nurse
chart
chief complaint (CC)
Chief Medical Information Officer (CMIO)
Chief Medical Officer (CMO)
chief resident
chronic disease
claim
claims review
clinic
clinical concept
clinical decision support system (CDSS or CDS)
A toolkit that analyzes data to enhance decision-making in the clinical workflow. The software assists physicians and health professionals in, for example, applying a particular diagnosis, specific tests or treatments for their patients
Clinical Document Architecture (CDA)
An XML-based markup standard to provide an exchange model for clinical documents
clinical documentation improvement (CDI)
The process, often supported by specialized software, that is intended for physicians to enhance their documentation of patient encounters and procedures.
clinical information system (CIS)
clinical intelligence apps (CI apps)
A voluntary, private sector organization for certifying health IT products, such as EHRs and the networks over which they interact
clinical pathway
Clinical Quality Language (CQL)
clinical reasoning
clinical research
clinical trial
clinician
closed ICU
CMS (CMS)
code status
cognitive computing
The simulation of human thought process in a computerized model. CC is a branch of artificial intelligence that uses machine learning and natural language processing to reproduce the way the human brain works. The purpose of cognitive computing is to build automated IT systems to solve problems without requiring human assistance.
community acquired
comorbidity
complication
computer on wheels (COW)
computer-assisted coding system (CACS)
Software that utilizes natural-language processing to analyze healthcare documents and generate appropriate medical codes for specific phrases and terms within the document.
computerized practitioner order entry (CPOE)
The process of listing electronic orders for medications and tests using computerized clinical decision support
constellation of symptoms
consultant
consulting team
continuing education
continuity of care
continuity of care record (CCR)
A standard for creating and providing timely access to electronic summaries of patient health for other caregivers.
contraindication
controlled medication
copayment
county hospital
coverage status
covered benefit
covered entity
curbside consult
D
delay in diagnosis
department
department chair
device representative
diagnosis
dictation
diet
Digital Imaging and Communications in Medicine (DICOM)
A standard for storing and transferring medical pictures enabling the integration of medical imaging devices and PACSs from various producers.
direct project
A system of healthcare interventions and communications for maintaining care and support for patients with chronic illness such as diabetes, HIV/AIDS, and cancer.
disability
discharge
discharge criteria
discharge planning
disease management
A system of healthcare interventions and communications for maintaining care and support for patients with chronic illness such as diabetes, HIV/AIDS, and cancer.
disorder
doctor
documentation burden
drug dosage
drug duration
drug form
drug frequency
drug representative
drug strength
drug timing
durable power of attorney
E
e-consult
e-prescription
A computer-generated appointment created by a healthcare provider and sent directly to pharmacies to avoid paperwork, phone calls or possible fraud.
electronic health record (EHR)
A patient’s official health document that is shared among multiple medical organizations. All records are stored in a digital format and include the same types of information, like contact and insurance details, a list of medications and surgeries or procedures performed, etc.
electronic intensive care unit (eICU)
A form of tele-medicine that uses state-of-the-art monitoring tools to keep an eye on patient’s state of health within the country
electronic medical record (EMR)
The patient record created by providers for specific encounters in hospitals and ambulatory environments. The data may be exportable to an EHR.
electronic protected health information (PHI)
EMT
encounter
end of life care
episode of care
F
family history
Fast Healthcare Interoperability Resources (FHIR)
A standard for electronic exchange of healthcare information. FHIR can be used in mobile apps, cloud communications, EHR-based data sharing and among institutional healthcare providers.
Federal Health Architecture (FHA)
An e-government initiative that coordinates health IT activities among federal agencies responsible for providing medical services. The FHA helps federal institutions invest in standards-compliant technology and ensure the accountability of governmental health IT programs
fee for service
fellow
fellowship
FHIR resource
first call
floor
fluid balance
follow up (f/u)
following a patient
Food and Drug Administration (FDA)
A legal act which classifies medical devices into three categories based on the associated risk to ensure safety and effectiveness of the gadgets.
formulary
G
General Data Protection Regulation (GDPR)
The set of rules that requires private and public healthcare sectors to demonstrate they are protecting their patients’ data adequately. Any healthcare provider must verify their patients’ identities and organize a system that allows the erasure or rectification of their data. Applicable for companies in EU or targeting EU citizens.
generic drug name
group practice
H
halfway home
health care system
Health Employers Data Information Set (HEDIS)
A set of standardized performance measures used by healthcare professionals to compare the quality and services provided by health plans, group practices, and hospitals.
health information exchange (HIE)
Reliable and secure sharing of the healthcare-related data among institutions, health information organizations and government facilities in compliance with national standards.
health information organization (HIO)
Is a U.S. government-led non-profit medical institution which transfers healthcare info electronically across organizations, including smaller clinics, hospitals, medical societies, major employers, and payers
health information technology (HIT)
An IT field which involves development, use, and support of information systems for the healthcare industry. Automated and interoperable healthcare information systems are expected to improve medical care, lower costs, increase efficiency and reduce error, while optimizing reimbursement for ambulatory and inpatient healthcare providers
Health Information Technology for Economic and Clinical Health (HITECH Act)
U.S. legislation passed in 2009 to encourage the adoption of electronic health records and the supporting technology.
Health Insurance Portability and Accountability Act of 1996 (HIPAA)
Health Level Seven International (HL7)
A set of standards, guidelines, and methodologies for transfer, integration, and retrieval of healthcare information. In theory, the ability to exchange data should minimize the tendency for medical care to be geographically isolated and highly variable
health maintenance organization (HMO)
health risk assessment
HealthIT.gov
HIMSS (HIMSS)
HIPAA (HIPAA)
U.S. legislation that provides data privacy and security provisions for safeguarding medical data. HIPAA Privacy Rules protects sensitive patient info by establishing a set of rights and standards that apply to healthcare provides gathering and storing it electronically or otherwise.
HIPAA Privacy Rule
HIPAA Security Rule
history and physical exam (H&P)
history of present illness
HITRUST
HL7v2 message
holistic medicine
home call
home care
home grown applications
home health
home medications
home monitoring
The use of technology to remotely monitor a patient’s medical history from their home to enhance their comfort
hospice
hospital
hospital acquired infection
hospital day
hospital information system (HIS)
A computer system that addresses mainly the administrational needs of hospitals. They manage the data related to the finance department, laboratory, nursing (NIS), pharmacy (PIS), radiology (RIS) and pathology departments
hospitalist
I
iatrogenic
idiopathic
illness script
imaging
impression
in network
incidence
indwelling
informed consent
inpatient
intake and output
intensive care unit
interdisciplinary rounds
intern
International Classification of Diseases (ICD)
A system used by healthcare providers to categorize and code all diagnoses, symptoms, and procedures.
International Review Board (IRB)
interoperability
interpreter
intervention
intraoperative
isolation
J
Joint Commission on the Accreditation of Healthcare Organizations (JCAHO)
junior resident
justice
L
laboratory panel
labs
language services
lethal dose
line
LOINC (LOINC)
loss to followup
low code development
M
MACRA
malpractice
Meaningful Use (MU)
The U.S. government EHR incentive program, which sets the standards for using health records and exchanging patient clinical data between healthcare providers, insurers, and patients.
medical algorithm
A step-by-step protocol to address medical challenges like diagnosis or screening. Usually, it is represented as a flowchart or stepwise instruction.
medical error
medical ethics
medical evidence
medical history
medical informatics
medical practice management software
A toolkit that is used to manage day-to-day operations of a medical practice, such as appointment scheduling, billing tasks performing and report generating.
medical record number (MRN)
medical research
medical scheduling software
A solution for managing patient appointments and allocating medical staff
medical student
Medicare
medication administration reconciliation (MAR)
MIPS
mobile health (mHealth)
The accessibility and exchange of clinical and patients’ information via mobile devices and apps.
morbidity and mortality
N
National Council for Prescription Drug Programs (NCPDP)
A non-profit ANSI-accredited organization that manages a number of standards to improve the communication within the pharmacy industry.
National Health Information Network (NHIN)
A set of technologies, standards, policies, programs, and practices that enable medical data to be shared among healthcare decision makers to improve the industry.
National Practitioner Data Bank
National Provider Identifier (NPI)
negative predictive value
neotatal intensive care unit
next of kin
night float
nonmaleficence
note
notification overload
NPO
nurse practitioner
nursing flowsheet
nursing station
O
objective
observation
occupational therapy
off service
Office for Civil Rights (OCR)
Office of the National Coordination of Health Information Technology (ONC)
A federal institution that regulates and standardizes health technology for general usage in the U.S.
on call
one liner
onset
open ICU
OpenNotes
operation
opiate
organs based curriculum
osteopathic medicine
out of network
out-of-pocket-cost
outcome
outpatient
outpatient procedure
outside hospital
overnight events
P
page forwarding
pager systems
paramedic
pathogenesis
pathology
patient
patient centered care
patient encounter costing (PEC)
A cost accounting system that is used to record, analyze, and allocate costs for the individual services provided to patients, such as medications, procedures, analysis, and boarding.
patient health record
patient identifiers
patient labels
patient list
patient portal
A website that allows patients access personal health information and communicate with their healthcare providers online.
patient presentation
patient safety
pending
periopertive
personal health information (PHI)
Medical history, laboratory results, insurance info and other data that a healthcare professional stores to identify an individual and determine appropriate care.
personal health record (PHR)
A collection of patient’s self-maintained health-related information. PHRs are stored on a personal device or the Internet and can be shared with third parties only with the consent of the owner.
physical exam
physical therapy
physician assistant
Physician Quality Reporting System (PQRS)
A quality improvement program initiated to determine whether physicians should have their Medicare payments adjusted up or down.
physiology
Picture Archiving and Communication Systems (PACS)
A healthcare imaging technology which provides economical storage and convenient access to the content, including computed tomography (CT) and magnetic resonance imaging (MRI) results.
Pixis
plain language
plan
point of care (POC)
point of service (POS)
POLST (POLST)
population health
population health management (PHM)
A discipline that studies and facilitates medical assistance across the general population or a group of individuals.
positive predictive value
post graduate year (PGY)
postop day
postoperative
practice guidelines
pre-authorization
precautions
preferred provider organization (PPO)
premium
preoperative
prerounding
prescription
presentation
prevalence
primary care practitioner (PCP, PMD)
primary diagnosis
primary team
principle investigator
private practice
PRN (PRN)
problem
problem based charting
problem based learning
procedure
prognosis
progress note
prophylaxis
protected health information (PHI)
Any part of a patient’s medical record or payment history that can be used for de-identification before researchers share the dataset publicly.
provider
provocation and palliation
public health
Pubmed
Q
quality
quality assurance
quality improvement
quality of life measures
quality-adjusted life year (QALY)
R
radiology information system (RIS)
recommendation
recurrence
referral
referral center
referral source
region and radiation
registered nurse
relative value units
remote monitoring
Differs from home monitoring with a broader coverage area. The tools are applied to a patient anywhere and send alerts to a nurse station if their condition worsens, reducing the need for close personal monitoring.
report
residency program
resident
resolution
retrospective review process
return precautions
return to work
revenue cycle management (RCM)
A financial process that healthcare facilities use to track patients care episodes from registration and appointment scheduling to the final payment.
review of systems
role
rotation
rounds
routine
running the list
rural health clinic
S
same day surgery
scheduled medication
screening
scribe
script
secondary diagnosis
Secretary of the U.S. Department of Health and Human Services (HHS)
sensitivity
sequela
service
service pager
severity
shared decision making
sign
sign off
signateur
signout
sitter
skilled nursing facility (SNF)
SNOMED (SNOMED)
social history
social worker
specialist
specificity
standing medication
stat
step down unit
studies
subjective
supportive care
surgical history
surgical intensive care unit
susceptibility
symptom
syndrome
systems based curriculum
T
team
technician
telemedicine
The adoption of telepresence or video conferencing to maintain medical consultations or treatments remotely.
telemetry
tertiary care hospital
text expansion
therapeutic dose
time out
timing
transcription
transfer
trauma center
traveling nurse
treatment decision support
A set of tools and processes that are used by patients who will receive the treatment to improve their healthcare decision-making.
triage
tube
U
UMLS Terminology Services
unsolicited data
urgent care
USPSTF (USPSTF)
utilization review (UR)
V
validation criterion
vendor neutral archive (VNA)
A medical imaging technology in which images and documents are archived in a standard format and accessible to healthcare professionals regardless of what proprietary system created the files.
virtual visit
A model of healthcare services provision that is based on remote consultations through video or voice connection.