# Records and Interoperability Glossary

> 75 terms from the Health Tech book's Records and Interoperability part, each defined in a line and linked to the chapter that explains it.

- **A40 (merge patient):** the HL7 v2 ADT event telling a receiver that two patient identifiers now refer to one patient ([HL7 v2 & Interfaces](https://www.syntaqx.com/books/health-tech/hl7-v2#the-messages-that-run-a-practice)).
- **ACK (acknowledgment):** the HL7 v2 reply that takes custody of a message: AA, AE or AR in original mode, CA, CE or CR for an enhanced-mode commit ([HL7 v2 & Interfaces](https://www.syntaqx.com/books/health-tech/hl7-v2#acknowledgments)).
- **Addendum:** information added to a signed note under a new date and signature, leaving the original unchanged ([EHRs, PMSs & the Clinical Record](https://www.syntaqx.com/books/health-tech/ehr-and-pms-data#notes-and-signatures)).
- **ADT (admission, discharge and transfer):** the HL7 v2 patient administration feed carrying registrations, visits, demographics updates and merges ([HL7 v2 & Interfaces](https://www.syntaqx.com/books/health-tech/hl7-v2#the-messages-that-run-a-practice)).
- **Amendment (HIPAA):** a patient's request to change information in the designated record set, decided within 60 days with one 30-day extension ([EHRs, PMSs & the Clinical Record](https://www.syntaqx.com/books/health-tech/ehr-and-pms-data#amendments)).
- **Backend Services (SMART):** server-to-server authorization with a signed JWT and system scopes, no user involved ([SMART on FHIR & App Platforms](https://www.syntaqx.com/books/health-tech/smart-on-fhir#backend-services)).
- **Bridge (dental imaging):** a link that launches imaging software on the same patient from the practice management system, by command line or file ([C-CDA, Documents & Images](https://www.syntaqx.com/books/health-tech/documents-and-ccda#dental-imaging-and-bridges)).
- **Bulk Data ($export):** FHIR's asynchronous export of many patients' data as NDJSON files, by patient, group or system ([FHIR](https://www.syntaqx.com/books/health-tech/fhir#bulk-data-export)).
- **C-CDA (Consolidated Clinical Document Architecture):** the US library of CDA XML templates for clinical documents such as the CCD, referral note and discharge summary ([C-CDA, Documents & Images](https://www.syntaqx.com/books/health-tech/documents-and-ccda#c-cda)).
- **CapabilityStatement:** the FHIR resource a server returns at `/metadata` listing the resources, interactions, searches and guides it supports ([FHIR](https://www.syntaqx.com/books/health-tech/fhir#resources-and-the-rest-api)).
- **CCD (Continuity of Care Document):** the C-CDA summary of a patient's current state, the document networks return when asked for the record ([C-CDA, Documents & Images](https://www.syntaqx.com/books/health-tech/documents-and-ccda#c-cda)).
- **CDS Hooks:** an HL7 standard for an EHR to call outside decision support at workflow points such as opening a chart or signing an order, returning cards ([FHIR](https://www.syntaqx.com/books/health-tech/fhir#cds-hooks)).
- **CDT (Code on Dental Procedures and Nomenclature):** the ADA's copyrighted, yearly-updated HIPAA code set for dental services ([Terminologies & Code Sets](https://www.syntaqx.com/books/health-tech/terminology-and-coding#cdt)).
- **Chart status (dental):** the state of a charted procedure: treatment planned, complete, existing current or other provider, referred out, or a condition ([EHRs, PMSs & the Clinical Record](https://www.syntaqx.com/books/health-tech/ehr-and-pms-data#dental-teeth-surfaces-and-status)).
- **CommonWell:** an EHR vendor alliance running a master person index and record locator service, and a designated QHIN ([Networks & Exchange](https://www.syntaqx.com/books/health-tech/health-information-exchange#kinds-of-networks)).
- **CPT (Current Procedural Terminology):** the AMA's copyrighted code set for physician and professional services, HCPCS Level I ([Terminologies & Code Sets](https://www.syntaqx.com/books/health-tech/terminology-and-coding#cpt)).
- **Credential service provider (CSP):** a service that proofs a person's identity and issues a credential, such as an IAL2 claims token for TEFCA individual access ([Patient Matching & Identity](https://www.syntaqx.com/books/health-tech/patient-matching-and-identity#identity-proofing-and-ial2)).
- **CVX:** CDC's code set for vaccines administered, paired with MVX manufacturer codes ([Terminologies & Code Sets](https://www.syntaqx.com/books/health-tech/terminology-and-coding#the-clinical-code-sets)).
- **Designated record set:** the medical and billing records, and any records used to make decisions about individuals, that HIPAA's access and amendment rights reach ([EHRs, PMSs & the Clinical Record](https://www.syntaqx.com/books/health-tech/ehr-and-pms-data#the-legal-medical-record)).
- **DFT (detail financial transaction):** the HL7 v2 message that posts charges, payments and adjustments to a billing system ([HL7 v2 & Interfaces](https://www.syntaqx.com/books/health-tech/hl7-v2#the-messages-that-run-a-practice)).
- **DICOM (Digital Imaging and Communications in Medicine):** the international standard for medical images and their metadata, ISO 12052 ([C-CDA, Documents & Images](https://www.syntaqx.com/books/health-tech/documents-and-ccda#dicom-pacs-and-dicomweb)).
- **DICOMweb:** DICOM's RESTful services: QIDO-RS to query, WADO-RS to retrieve, STOW-RS to store and UPS-RS for worklists ([C-CDA, Documents & Images](https://www.syntaqx.com/books/health-tech/documents-and-ccda#dicom-pacs-and-dicomweb)).
- **Direct (secure messaging):** S/MIME-encrypted email between providers' Direct addresses through HISPs, the certified push for referrals ([C-CDA, Documents & Images](https://www.syntaqx.com/books/health-tech/documents-and-ccda#direct-secure-messaging)).
- **Duplicate (patient):** one person with two records in the same system, fixed by a merge ([Patient Matching & Identity](https://www.syntaqx.com/books/health-tech/patient-matching-and-identity#duplicates-overlays-and-overlaps)).
- **eHealth Exchange:** a network of networks whose participants, federal agencies among them, sign the DURSA; a designated QHIN ([Networks & Exchange](https://www.syntaqx.com/books/health-tech/health-information-exchange#kinds-of-networks)).
- **EHR (electronic health record):** the clinical half of a practice's software: problems, medications, allergies, notes, orders and results ([EHRs, PMSs & the Clinical Record](https://www.syntaqx.com/books/health-tech/ehr-and-pms-data#ehr-pms-or-both)).
- **EHR launch:** a SMART launch from inside the EHR, which passes `iss` and `launch` so the app opens in the clinician's current context ([SMART on FHIR & App Platforms](https://www.syntaqx.com/books/health-tech/smart-on-fhir#the-two-launches)).
- **EMPI (enterprise master patient index):** the registry linking every local identifier for a patient across an organization's systems to one identity ([Patient Matching & Identity](https://www.syntaqx.com/books/health-tech/patient-matching-and-identity#the-master-patient-index)).
- **Exchange purpose:** the reason asserted for a network query (treatment, payment, operations, public health, government benefits, individual access), which decides who must answer ([Networks & Exchange](https://www.syntaqx.com/books/health-tech/health-information-exchange#tefca-as-of-october-2026)).
- **FDI/ISO notation:** two-digit tooth numbering whose first digit is the quadrant, 11 to 48 for permanent teeth and 51 to 85 for primary ([EHRs, PMSs & the Clinical Record](https://www.syntaqx.com/books/health-tech/ehr-and-pms-data#dental-teeth-surfaces-and-status)).
- **FHIR (Fast Healthcare Interoperability Resources):** HL7's REST standard for health data as typed JSON resources; R4 is the US production version ([FHIR](https://www.syntaqx.com/books/health-tech/fhir)).
- **HCPCS Level II:** CMS's alphanumeric codes for supplies, equipment, drugs and services outside CPT, updated quarterly ([Terminologies & Code Sets](https://www.syntaqx.com/books/health-tech/terminology-and-coding#hcpcs-level-ii)).
- **HIE (health information exchange):** a regional or state organization, or the practice generally, of sharing records between organizations ([Networks & Exchange](https://www.syntaqx.com/books/health-tech/health-information-exchange#kinds-of-networks)).
- **HISP (health information service provider):** the service that sends and receives Direct messages and manages certificates for its users ([C-CDA, Documents & Images](https://www.syntaqx.com/books/health-tech/documents-and-ccda#direct-secure-messaging)).
- **HL7 v2:** the pipe-delimited event messaging standard that runs most hospital interfaces, used by 95% of US health care organizations in 2024 ([HL7 v2 & Interfaces](https://www.syntaqx.com/books/health-tech/hl7-v2)).
- **IAL2 (identity assurance level 2):** NIST's remote or on-site identity proofing with stronger evidence and verification, the bar for TEFCA individual access ([Patient Matching & Identity](https://www.syntaqx.com/books/health-tech/patient-matching-and-identity#identity-proofing-and-ial2)).
- **ICD-10-CM:** the US diagnosis code set maintained by CDC's NCHS, released by fiscal year from October 1 with April updates ([Terminologies & Code Sets](https://www.syntaqx.com/books/health-tech/terminology-and-coding#icd-10-cm-and-icd-10-pcs)).
- **ICD-10-PCS:** CMS's procedure code set for hospital inpatients ([Terminologies & Code Sets](https://www.syntaqx.com/books/health-tech/terminology-and-coding#icd-10-cm-and-icd-10-pcs)).
- **Implementation guide (IG):** a package of FHIR profiles, searches and examples that narrows the base standard for a use case, such as US Core ([FHIR](https://www.syntaqx.com/books/health-tech/fhir#profiles-us-core-and-implementation-guides)).
- **Individual access services (IAS):** TEFCA's exchange purpose letting a person's approved app retrieve their own records after IAL2 proofing ([Networks & Exchange](https://www.syntaqx.com/books/health-tech/health-information-exchange#individual-access-services)).
- **Interface engine:** middleware that receives, transforms, routes and stores interface messages between systems, such as Rhapsody, Mirth Connect, Iguana or Cloverleaf ([HL7 v2 & Interfaces](https://www.syntaqx.com/books/health-tech/hl7-v2#interface-engines)).
- **LOINC:** the code system for lab tests, observations and document types ([Terminologies & Code Sets](https://www.syntaqx.com/books/health-tech/terminology-and-coding#the-clinical-code-sets)).
- **MBI (Medicare Beneficiary Identifier):** Medicare's 11-character random identifier that replaced SSN-based claim numbers ([Patient Matching & Identity](https://www.syntaqx.com/books/health-tech/patient-matching-and-identity#no-national-identifier)).
- **MLLP (Minimal Lower Layer Protocol):** the TCP framing for HL7 v2: a 0x0B start byte, then 0x1C and 0x0D at the end, with no security of its own ([HL7 v2 & Interfaces](https://www.syntaqx.com/books/health-tech/hl7-v2#mllp-the-transport)).
- **MPI (master patient index):** the registry of every patient an organization knows, which matches, links and merges them ([Patient Matching & Identity](https://www.syntaqx.com/books/health-tech/patient-matching-and-identity#the-master-patient-index)).
- **NDC (National Drug Code):** FDA's three-segment drug package identifier, moving to a uniform 12-digit format effective March 7, 2033 ([Terminologies & Code Sets](https://www.syntaqx.com/books/health-tech/terminology-and-coding#ndc)).
- **Odontogram:** the tooth chart on which dental findings and procedures are recorded by tooth and surface ([EHRs, PMSs & the Clinical Record](https://www.syntaqx.com/books/health-tech/ehr-and-pms-data#dental-teeth-surfaces-and-status)).
- **ORU (observation result):** the HL7 v2 message carrying lab and other results as OBR and OBX segments ([HL7 v2 & Interfaces](https://www.syntaqx.com/books/health-tech/hl7-v2#the-messages-that-run-a-practice)).
- **Overlay:** two people's information on one record, the dangerous matching error, fixed by an unmerge and a clinical review ([Patient Matching & Identity](https://www.syntaqx.com/books/health-tech/patient-matching-and-identity#duplicates-overlays-and-overlaps)).
- **PACS (picture archiving and communication system):** the server that stores medical images and serves them to viewers ([C-CDA, Documents & Images](https://www.syntaqx.com/books/health-tech/documents-and-ccda#dicom-pacs-and-dicomweb)).
- **Patient discovery:** the first step of a network query, sending demographics so each responder can match and return its local identifier ([Networks & Exchange](https://www.syntaqx.com/books/health-tech/health-information-exchange#query-push-and-notify)).
- **Plan of care (therapy):** a therapy plan with diagnosis, goals and treatment frequency and duration, which Medicare requires certified and recertified at least every 90 days ([EHRs, PMSs & the Clinical Record](https://www.syntaqx.com/books/health-tech/ehr-and-pms-data#physical-therapy-the-plan-of-care)).
- **PMS (practice management system):** the business half of a practice's software: schedule, demographics, insurance, charges, claims and the ledger ([EHRs, PMSs & the Clinical Record](https://www.syntaqx.com/books/health-tech/ehr-and-pms-data#ehr-pms-or-both)).
- **Problem list:** a patient's coded current and past conditions, distinct from the diagnoses billed for one encounter ([EHRs, PMSs & the Clinical Record](https://www.syntaqx.com/books/health-tech/ehr-and-pms-data#what-the-clinical-record-holds)).
- **Profile (FHIR):** a set of constraints on a resource (required and must-support elements, bound value sets, extensions) ([FHIR](https://www.syntaqx.com/books/health-tech/fhir#profiles-us-core-and-implementation-guides)).
- **QHIN (Qualified Health Information Network):** a network designated by the RCE to exchange under TEFCA's Common Agreement; 11 as of October 2026 ([Networks & Exchange](https://www.syntaqx.com/books/health-tech/health-information-exchange#tefca-as-of-october-2026)).
- **RCE (Recognized Coordinating Entity):** The Sequoia Project, which designates QHINs and maintains TEFCA's SOPs under contract with ASTP/ONC ([Networks & Exchange](https://www.syntaqx.com/books/health-tech/health-information-exchange#tefca-as-of-october-2026)).
- **Record locator service:** a network service that says which members hold records for a person ([Networks & Exchange](https://www.syntaqx.com/books/health-tech/health-information-exchange#kinds-of-networks)).
- **Referential matching:** patient matching that consults third-party identity data from outside health care to link records ([Patient Matching & Identity](https://www.syntaqx.com/books/health-tech/patient-matching-and-identity#matching-methods)).
- **RxNorm:** NLM's normalized names for clinical drugs, each with an RXCUI, linking prescriptions to NDCs and commercial drug databases ([Terminologies & Code Sets](https://www.syntaqx.com/books/health-tech/terminology-and-coding#the-clinical-code-sets)).
- **SIU (scheduling information unsolicited):** the HL7 v2 appointment notifications, S12 booked through S26 no-show ([HL7 v2 & Interfaces](https://www.syntaqx.com/books/health-tech/hl7-v2#the-messages-that-run-a-practice)).
- **SMART App Launch:** the OAuth 2.0 profile for FHIR apps, covering launch context, v2 scopes, PKCE and discovery; 2.0.0 is the certification baseline ([SMART on FHIR & App Platforms](https://www.syntaqx.com/books/health-tech/smart-on-fhir)).
- **SNOMED CT:** the clinical terminology for findings, disorders and procedures, distributed in the US by NLM in March and September editions ([Terminologies & Code Sets](https://www.syntaqx.com/books/health-tech/terminology-and-coding#the-clinical-code-sets)).
- **SOAP note:** the note structure of subjective, objective, assessment and plan, used across medicine, dentistry, therapy and veterinary care ([EHRs, PMSs & the Clinical Record](https://www.syntaqx.com/books/health-tech/ehr-and-pms-data#notes-and-signatures)).
- **Standalone launch:** a SMART launch outside the EHR, in which the app requests context through scopes such as `launch/patient` ([SMART on FHIR & App Platforms](https://www.syntaqx.com/books/health-tech/smart-on-fhir#the-two-launches)).
- **Subscription (FHIR):** a client's request to be notified of events on a topic, by rest-hook or websocket, ideally with id-only payloads ([FHIR](https://www.syntaqx.com/books/health-tech/fhir#subscriptions-being-told)).
- **Taxonomy code:** the NUCC's ten-character code for a provider's type and specialty, used in HIPAA transactions and on the NPI application ([Terminologies & Code Sets](https://www.syntaqx.com/books/health-tech/terminology-and-coding#the-clinical-code-sets)).
- **TEFCA (Trusted Exchange Framework and Common Agreement):** the federal framework connecting networks through QHINs under one agreement, live since December 2023 ([Networks & Exchange](https://www.syntaqx.com/books/health-tech/health-information-exchange#tefca-as-of-october-2026)).
- **Universal tooth numbering:** the US system numbering permanent teeth 1 to 32 and primary teeth A to T ([EHRs, PMSs & the Clinical Record](https://www.syntaqx.com/books/health-tech/ehr-and-pms-data#dental-teeth-surfaces-and-status)).
- **US Core:** the US national FHIR implementation guide expressing USCDI; 6.1.0 was the certification baseline by December 31, 2025 ([FHIR](https://www.syntaqx.com/books/health-tech/fhir#profiles-us-core-and-implementation-guides)).
- **USCDI (United States Core Data for Interoperability):** ASTP/ONC's versioned list of data classes certified health IT must exchange; v3 is the certification baseline ([EHRs, PMSs & the Clinical Record](https://www.syntaqx.com/books/health-tech/ehr-and-pms-data#what-the-clinical-record-holds)).
- **Value set:** a purpose-built list of codes from one or more code systems, with a definition and dated expansions ([Terminologies & Code Sets](https://www.syntaqx.com/books/health-tech/terminology-and-coding#value-sets)).
- **VSAC (Value Set Authority Center):** NLM's repository of public value sets, including CMS's eCQM value sets ([Terminologies & Code Sets](https://www.syntaqx.com/books/health-tech/terminology-and-coding#value-sets)).
- **X12:** the standards body and format for HIPAA's administrative transactions: 837 claims, 835 remittances, 270/271 eligibility, 276/277 claim status, 278 authorizations ([The Health Tech Business](https://www.syntaqx.com/books/health-tech/health-tech-business#fee-for-service-through-insurance)).
- **Z segment:** a locally defined HL7 v2 segment, where each interface keeps the fields the standard doesn't have ([HL7 v2 & Interfaces](https://www.syntaqx.com/books/health-tech/hl7-v2#anatomy-of-a-message)).

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