Healthcare Terminology and Acronyms


ADC – Automated dispensing cabinet, for Pharmacy

ADL -activities of daily living

ASC – Advanced Surgical Center

ASTM – American Society for Testing and Materials

ATCB – ONC Authorized Testing and Certification Body

BAA – Business Associate Agreement, required of third parties when providers share records with them (a BAA is NOT required from postal carriers)

CAH – Critical Access Hospitals (paid based on cost, not diagnosis)

CCD – Continuity of Care Document, an XML-based standard

CMS – Center for Medicare and Medicaid Services, a division of HHS

CPOE – Computerized Physician Order Entry: Lab, Rad and Pharmacy

CPT – Current Procedural Terminology

CSW – Clinical Social Worker

EDIS – Emergency department IS

eMAR – an electronic medication administration record, for Pharmacy, using barcode scanners at several points in the process

EPHI – Electronic Protected Health Information; Electronically transmitted or stored information

ERISA – Employee Retirement Income Security Act of 1974

Health Records:

EMR – Electronic Medical Records, usually in a stand-alone situation like a doctor’s office; an electronic version of the paper record.

EHR – Electronic Health Records are a collection of patient or population health information. One patient’s records from multiple sources and providers collectively are her EHR.

EPR – same as EHR

PHR – Personal Health Record, an electronic record maintained by the individual

HCPCS – Healthcare Common Procedure Coding System –

HHS – Department of Health and Human Services, the federal colossus

HITSP – Healthcare Information Technology Standards Panel

Information Systems


Pharmacy IS

Radiology IS

Lab IS (LIS)

IRB – Institutional Review Board

MAR –  Medication Administration Record, for Pharmacy (cf. eMAR)

MOU – Memorandum of Understanding, or MOA, Memorandum of Agreement

NPI – National Provider Identifier

OCR – Office for Civil Rights

ONC – Office of the National Coordinator for Health Information Technologies

PACS – Picture Archiving and Communication System

PERT (chart) – Program Evaluation and Review Technique

Physician portal – a view into HIS/EMR/EHR; unlike CPOE it’s for notes, not orders; allows electronic signatures

PPACA or ACA – Patient Protection and Affordable Care Act

PPS – Prospective Payment System (payment based on diagnosis, not cost), a Medicare Part A system

RECs – HIT Regional Extension Centers

Surgical Process

Surgical summary report – short, for immediate reference during postop

Cold feed – how the report above is sent; there is no ACK confirming receipt

Operative record – complete, detailed account, dictated

SNF – Skilled Nursing Facility

TPO – Treatments, payments and operations



-osis – condition or disease

-itis – inflammation – Arthritis is inflammation

-algia – pain

-crine – secreting, as in endocrine

-blast – an immature or forming condition

-ology – study of



Barium contrast – a video using injected barium to make objects show clearly

Echocardiogram – a video view of the heart

Electronic signature – a scanned copy of a signature on paper

Data Security – technical and procedural methods to control and manage confidential information.

Digital signature – a product of hashing and encryption with full legal legitimacy

Health Information

De-identified Health Information

Individually Identifiable Health Information

Archived Health Information

Demographic Health Information

Informed Consent – the conversation between patient and physician re. medical procedure being performed, reasons for it, benefits of it and risks.

Interface Engine – a “translator” that sits between multiple systems and reformats data for those systems

Nursing home vs. assisted living

Perioperative IS – the info system that manages patients in surgery

Privacy – “the individual’s right to control disclosure”

Specialty Hospital provides treatment for specific issues such as burns, cancer or women’s care

Thinning – reducing a patient’s chart when it gets too big to handle. Thinned records are sent to central medical records area.


Types of Plans

A Preferred Provider Organization (PPO) offers discounted services at in-network providers only.

A Health Maintenance Organization (HMO) provides services for a fixed, prepaid amount.


Types of IT in Medicine

Clinical IT – handling prescriptions, lab tests, images, medical procedures

Infrastructure IT – handling networks and major services

Financial IT – handling billing and finances

Administrative IT – handling staffing and operations IT


Types of Data




Signals – tracking from an instrument, e.g. EEG or EKG