Glossary
The clinic and health system glossary
40 terms clinics, groups and health systems search for, from AI scribe to revenue cycle management, each defined in two sentences you can quote. Every entry says why the term matters to a clinic and how wai handles it today.
Updated .
Documentation
- AI scribeAn AI scribe is software that listens to a consultation, in the room or on video, and drafts the clinical note from the conversation.
- Ambient clinical documentationAmbient clinical documentation is the use of software that listens to the natural conversation between a clinician and a patient and drafts the clinical note from it, with no dictation or typing during the visit.
- Clinical codingClinical coding is the translation of diagnoses, procedures and other clinical information in a patient record into standard codes, such as ICD-10 for diagnoses or SNOMED CT for clinical terms.
- Clinical decision supportClinical decision support is any tool that gives a clinician relevant knowledge or patient information at the point of a decision, such as guideline recommendations, alerts, reminders or summaries of the record.
- E-prescribingE-prescribing is the creation, signing and transmission of a prescription in electronic form, from the prescriber to the pharmacy, in place of a paper prescription.
- ICD-10 codingICD-10 coding is the assignment of codes from the tenth revision of the International Classification of Diseases, published by the World Health Organization, to the diagnoses and reasons for a visit in a patient record.
- Medical transcriptionMedical transcription is the conversion of spoken clinical information, such as a clinician's dictation or a recorded consultation, into written text for the patient record.
- Referral letterA referral letter is a letter from one clinician to another, or to a service, asking them to assess or take over part of a patient's care.
- Safety-nettingSafety-netting is the advice a clinician gives a patient at the end of a consultation about which symptoms or changes should prompt them to seek help, how urgently and where to go.
- SNOMED CTSNOMED CT is a structured clinical terminology, maintained by SNOMED International, that gives findings, diagnoses, procedures and other clinical concepts a unique code and defined relationships to one another.
- SOAP noteA SOAP note is a structured clinical note in four parts, subjective (what the patient reports), objective (examination findings and results), assessment (the clinician's diagnosis or impression) and plan (treatment, tests, referrals and follow-up).
Billing and revenue
- Claims scrubbingClaims scrubbing is the check an insurance claim goes through before it is submitted, to catch missing details, wrong codes and mismatches that would get it rejected.
- Payment reconciliationPayment reconciliation is matching each payment a clinic receives, by card, bank transfer or insurer remittance, to the invoice and visit it pays for.
- Prior authorisationPrior authorisation is an insurer's approval, given before a treatment, test or prescription, that it will pay for that care.
- Revenue cycle managementRevenue cycle management (RCM) is the whole process a healthcare provider runs to be paid for care, from booking and registration through coding, billing and claims to the final payment.
Front desk
- AI receptionistAn AI receptionist is software that reads a clinic's incoming patient messages and calls, drafts the replies and proposes bookings, so the front desk answers faster.
- Appointment remindersAppointment reminders are messages a clinic sends a patient before a visit, by text, WhatsApp or email, with the time, place and how to change it.
- No-show rateA no-show rate is the share of booked appointments that patients miss without cancelling in time, often called the DNA (did not attend) rate in the UK.
- Online bookingOnline booking lets patients choose and confirm their own appointment on a clinic's website or app, at any hour, from the times a clinician is actually available.
- Patient portalA patient portal is a secure website or app where patients see their own health record, results, letters and invoices, and stay in touch with their clinic.
- Patient recallPatient recall is the process of inviting patients back when a review, test, vaccination or follow-up is due.
- Practice management softwarePractice management software is the system a clinic uses to run its operations, typically appointments, patient registration, billing, payments and reporting.
- TelehealthTelehealth is healthcare delivered at a distance, most often by video or phone consultation, along with remote follow-up and monitoring.
- TriageTriage is sorting patients and their requests by how urgently they need care and sending each one to the right person or service.
- Waitlist managementWaitlist management is keeping a list of patients who want an earlier appointment and offering them slots as they open through cancellations.
Records and interoperability
- Clinical audit trailA clinical audit trail is the time-stamped log of who viewed, created, changed or signed each part of a patient record.
- EHR versus EMRAn electronic medical record (EMR) is the digital version of the chart a single practice keeps on its own patients.
- HL7 FHIRHL7 FHIR (Fast Healthcare Interoperability Resources) is a standard from HL7 International for exchanging health data between systems as small, defined resources such as Patient, Condition and Observation.
- InteroperabilityInteroperability is the ability of different health IT systems to exchange information and use what they receive without anyone retyping it.
- Subject access requestA subject access request is a person asking an organisation for a copy of the personal information it holds about them, a right under UK GDPR.
Regulation and privacy
- Accreditation surveyAn accreditation survey is the on-site review an accrediting body runs to check whether a healthcare organisation meets its published standards.
- Business associate agreementA business associate agreement (BAA) is the contract HIPAA requires between a covered entity, such as a US medical practice, and a vendor that creates, receives, keeps or sends protected health information on its behalf.
- Consent managementConsent management is how a clinic records what each patient has agreed to, when they agreed, and on what information.
- CQC single assessment frameworkThe single assessment framework is how the Care Quality Commission assesses health and care providers in England, through 5 key questions and 34 quality statements.
- Data residencyData residency is the country or region where an organisation's data is physically stored and processed.
- DCB0129DCB0129 is the information standard that requires manufacturers of health IT systems used in health and care in England to manage the clinical risk of their products.
- DPIAA data protection impact assessment (DPIA) is the documented assessment an organisation carries out before processing personal data in a way likely to put people at high risk.
- DSPTThe Data Security and Protection Toolkit (DSPT) is the online self-assessment that organisations with access to NHS patient data and systems use to show they handle that data securely.
- HIPAAHIPAA, the Health Insurance Portability and Accountability Act of 1996, is the US federal law whose rules protect the privacy and security of patients' health information.
- Role-based access controlRole-based access control (RBAC) gives each person access to systems and records according to the role they hold, such as clinician, receptionist or practice manager.
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