HealthCare Terminology
Patient History Settings: Configuration within healthcare software where detailed records of a patient's past medical information, including diagnoses, treatments, and family history, are stored and managed.
Healthcare Settings: Environments where healthcare services are provided, including hospitals, clinics, long-term care facilities, and specialized care units.
Setting Up Clinic / Practice: The process of establishing a healthcare practice, involving space setup, equipment procurement, and regulatory compliance for patient care.
Setting Up Inpatient Facility: Establishing a facility where patients receive continuous care and monitoring, often including beds, medical equipment, and specialized staff.
Setting Up Laboratory: Preparing a medical laboratory with necessary equipment, safety protocols, and staff for conducting diagnostic tests and analyses.
Setting Up Pharmacy: Organizing a pharmacy to dispense medications, requiring space setup, inventory management, and adherence to regulatory standards.
Inpatient ADT (Admission, Discharge, and Transfer): A hospital system that manages patient admissions, discharges, and transfers to ensure accurate patient tracking and care continuity.
Medication: A substance prescribed or administered to treat, manage, or prevent health conditions, typically classified by usage, such as antibiotics or pain relievers.
Inpatient: A patient admitted to a hospital or healthcare facility for at least one overnight stay to receive medical care and treatment.
Inpatient Record: A comprehensive medical document detailing the assessments, treatments, and progress of a patient during their hospital stay.
Inpatient Medication Order: A physician’s written or electronic request for medications to be administered to a patient during their hospital stay.
Inpatient Medication Entry: The documentation or electronic entry of prescribed medications into the patient’s record, ensuring accurate administration during their stay.
Patient (PAT): An individual receiving medical care or treatment from a healthcare provider, including both inpatient and outpatient services.
Patient Registration (PR): The process of collecting and recording a patient’s personal, demographic, and insurance information for their medical record.
Patient History (PH): A comprehensive record of a patient's past medical conditions, treatments, and health issues, essential for informed care.
Family History (FH): Information on medical conditions and diseases within a patient's family, used to assess potential genetic or hereditary health risks.
Consultation: A meeting between a patient and a healthcare provider to discuss health concerns, receive advice, and plan treatment. It often involves reviewing medical history and conducting examinations.
Patient Appointment: A scheduled visit for a patient to receive medical care or consultation from a healthcare provider. Appointments can be for routine check-ups, follow-ups, or specialized care.
Appointment Type: A classification of scheduled visits based on purpose, such as new patient consultations, follow-up appointments, or urgent care visits. It helps in organizing and managing healthcare services.
Practitioner Schedule: A timetable outlining the availability of healthcare providers for patient appointments and consultations. It ensures efficient use of resources and maximizes patient access to care.
Clinical Procedure: A specific medical intervention or operation performed by healthcare professionals to diagnose, treat, or manage a patient's condition. Examples include surgeries, biopsies, or therapeutic procedures.
Clinical Procedures Template: A standardized format or guideline for documenting clinical procedures, ensuring consistency and completeness in patient records. It helps streamline workflow and improve quality of care.
Patient Encounter: An interaction between a patient and a healthcare provider during which medical services are delivered. This includes consultations, examinations, and treatment sessions.
Vital Signs: Measurements of essential bodily functions, including temperature, pulse, respiration, and blood pressure, used to assess a patient’s overall health status. Vital signs provide critical information for diagnosis and treatment.
Complaint and Diagnosis: The patient's reported symptoms or issues (complaint) and the healthcare provider's conclusion about the underlying condition (diagnosis). This information guides the treatment plan.
Fee Validity: The duration during which a medical service fee is applicable or remains unchanged. It ensures transparency and compliance with billing practices in healthcare.
Nursing Tasks: Specific duties performed by nursing staff in patient care, including administering medications, monitoring patient conditions, and assisting with daily activities. These tasks are essential for patient recovery and well-being.
Service and Medication Request: A formal request made by healthcare providers for specific medical services or medications needed for patient care. This process ensures that patients receive appropriate and timely treatments.
Treatment Plan: A detailed outline created by healthcare providers that describes the approach, goals, and steps for managing a patient’s health condition.
Prescription: A written order from a licensed healthcare provider specifying a medication, dosage, and instructions for patient use.
Laboratory: A facility equipped for medical testing and analysis of patient samples to aid in diagnosis, treatment, and research.
Lab Test Template: A standardized format outlining necessary details for conducting specific lab tests, ensuring consistency and accuracy.
Lab Test: A medical procedure analyzing patient samples (like blood or urine) to help diagnose, monitor, or treat health conditions.
Observation Template: A structured form used to record patient observations, ensuring that all relevant information is consistently documented.
Observation: A recorded clinical finding or measurement, such as vital signs or symptoms, used to assess patient health over time.
Sample Collection: The process of obtaining biological samples (like blood, saliva, or tissue) from a patient for diagnostic testing.
Diagnostic Report: A document summarizing lab or test results and findings to aid in diagnosis, treatment decisions, and patient care.
Admission (ADM): The process of formally admitting a patient into the hospital for treatment or observation.
Discharge (DC): The official release of a patient from hospital care after treatment completion.
Inpatient Order (IPO): Medical orders specifically designated for patients receiving in-hospital care.
Bed Assignment (BA): Allocating an available hospital bed to an admitted patient.
Room Assignment (RA): Assigning a specific hospital room for a patient’s stay based on care needs and availability.
Discharge Summary: A comprehensive document outlining a patient’s hospital course, treatment provided, and follow-up instructions, prepared upon discharge from care.
Rehabilitation and Physiotherapy: Medical practices aimed at restoring function, mobility, and quality of life for individuals recovering from injury, surgery, or chronic conditions.
Exercise Type: A specific form of physical activity prescribed to target particular muscles or health outcomes, such as strength, flexibility, or endurance.
Therapy Type: The category of therapeutic intervention used to address a patient’s needs, including physical, occupational, or speech therapy.
Therapy Plan: A structured outline of treatment goals, methods, and exercises designed to support a patient’s recovery or improvement in health.
Therapy Plan Template: A customizable form or guide used to create a personalized therapy plan for patients, ensuring a consistent and thorough approach.
Therapy Session: An individual appointment or meeting with a therapist to perform exercises and activities based on a therapy plan.
Patient Assessment Template: A structured form to evaluate a patient’s condition, symptoms, and needs, facilitating comprehensive and consistent assessments.
Patient Assessment: The process of evaluating a patient's physical, mental, or emotional health to guide treatment planning and monitor progress.
Records and Reports: Documents that track patient information, clinical activities, and healthcare outcomes, ensuring accurate, organized, and accessible healthcare data.
Patient Medical History: A comprehensive record of a patient’s past health conditions, treatments, and medications, used to inform current and future medical care.
Patient Appointment Analytics: Data analysis of patient appointments to identify trends, improve scheduling efficiency, and enhance patient access to healthcare services.
Inpatient Medication Orders Report: A record detailing all medications prescribed to hospitalized patients, supporting safe administration and medication tracking.
Healthcare Practitioner Master: This is the central record for each healthcare professional. It contains personal details, qualifications, specialization, license information, and availability.
Medical Department: It is a specialized division within a hospital focused on a specific field of medicine. Each department provides targeted care, diagnosis, and treatment for particular health conditions, such as those managed by cardiology or neurology.
Healthcare Service Unit: It is a facility or division within a healthcare system that provides specific medical services, treatments, or support. Each unit is staffed with professionals dedicated to addressing particular health needs, like emergency care or physical therapy.
Medical Code Standard: A system of rules and guidelines used to ensure consistent and accurate coding of medical diagnoses and procedures across healthcare settings.
Medical Code: An alphanumeric code representing specific medical diagnoses, treatments, or procedures, used for documentation and billing in healthcare.
ABDM (Ayushman Bharat Digital Mission): An initiative by the Government of India to create a digital health ecosystem, enabling secure access to health records and integrating healthcare services across the country.
Additional Terminology
Electronic Health Record (EHR) - Comprehensive patient medical record
Clinical Decision Support (CDS) - System-generated alerts and recommendations.
Health Information Exchange (HIE) - Sharing of patient data between providers.
Medical Coding (MC) - Assignment of codes for diagnoses and procedures.
Billing and Insurance Claims (BIC) - Financial transactions for healthcare services.