Examination of a patient by a physician to check for breast cancer by feeling and inspection. It is not the same as a mammogram and is performed in a doctor’s office during a Papanicolaou test and pelvic examination.

Computer-based patient record (CPR) that contains a collection of clinical key data from several sources. These data may be monitored and analyzed and are retrievable. The data can be assembled into reports or used for help in decision making. They can also be part of an institutional information warehouse or community or state health information system. Sometimes referred to as a data warehouse or clinical data warehouse (CDW).

Method used to provide clinical data to health care providers and clinicians with the use of embedded flags (e.g., alert to a case manager that a patient’s eligibility for a specific medical service is almost used up). CDSS is a major functional requirement to support a clinical or critical pathway.

In a workers’ compensation case, collection of data by a physician for assessing the health of an individual for the purpose of creating a medical management plan and beginning a course of treatment.

Medical cases that support clinical situations related to some evaluation and management services and shown in an appendix of the Current Procedural Terminology code book. These illustrations may be used as a tool in coding professional services for billing.

Computer system that maintains a database of actual patient information on active medical care and treatment. CIS may be used for supporting medical decisions. In expanded form, a CIS becomes an electronic health record system. Also called clinical system.

Workplace where diagnostic tests and procedures are performed on specimens that are directly related to the care of patients such as blood, infectious materials, saliva, and tissues.

Federal act established in 1988 that regulates laboratory certification and accreditation standards, quality control, proficiency testing, personnel standards, program administration, and safety measures for all freestanding laboratories including physician office laboratories (POLs). CLIA mandates that all laboratories have a CLIA certificate to receive payment from federal programs. Adopted by Medicare and Medicaid programs.

Person who, under the direction of a physician, performs various routine back office tasks in a hospital, clinic, or other health facility. These duties may consist of assisting with the physical examinations, taking x-rays, performing electrocardiograms, taking vital signs, weighing patients, obtaining urine specimens, and other medical-related activities. Also see administrative medical assistant.

Memo or concise written communication about contact with a patient that includes the date seen; description of signs and symptoms, treatment, and drugs administered; the patient’s reaction; and any changes in physical or emotional condition.