Medical Documentation Glossary

Essential terms for understanding AI-powered medical documentation in optometry practice.

AI & Technology Terms

AI Medical Scribe

An artificial intelligence system that listens to patient encounters, transcribes conversations, and automatically generates structured medical documentation in real-time. Modern AI scribes like Doctora achieve 95% accuracy and save practices 2-3 hours daily on documentation tasks.

Ambient Documentation

Hands-free recording technology that captures the entire patient encounter without requiring specific voice commands or button presses. The AI intelligently filters relevant clinical information from background conversation, allowing doctors to maintain natural patient interaction.

Voice Documentation

The process of creating clinical records through speech recognition, allowing doctors to document while maintaining eye contact with patients. Modern systems distinguish between clinical findings and casual dialogue with high accuracy.

Natural Language Processing (NLP)

AI technology that enables computers to understand, interpret, and generate human language. In medical documentation, NLP extracts clinical information from spoken words and structures it into proper medical records.

Medical Documentation Terms

SOAP Notes

A standardized documentation method organizing clinical notes into four sections: Subjective (patient complaints and history), Objective (exam findings and test results), Assessment (diagnosis and clinical impressions), and Plan (treatment recommendations and follow-up). Doctora's AI automatically structures conversations into this format.

Chief Complaint (CC)

The primary reason for a patient's visit, documented in the patient's own words. This forms the foundation of the medical encounter and guides the examination and treatment planning process.

History of Present Illness (HPI)

A chronological description of the development of the patient's present illness from the first sign or symptom to the present. Includes location, quality, severity, duration, timing, context, modifying factors, and associated signs/symptoms.

Review of Systems (ROS)

An inventory of body systems obtained through questioning to identify signs and symptoms that the patient may be experiencing. In optometry, this includes constitutional symptoms, eyes, ears/nose/throat, cardiovascular, respiratory, and other relevant systems.

EHR & Integration Terms

Electronic Health Record (EHR)

A digital version of a patient's medical history, maintained by healthcare providers over time. EHRs include demographics, progress notes, medications, vital signs, past medical history, immunizations, laboratory data, and radiology reports. Doctora integrates with RevolutionEHR, Eyefinity, and 10+ other optometry EHRs.

EHR Integration

The technical connection between Doctora and electronic health record systems, enabling automatic transfer of documentation without manual copy-paste. This includes API connections and browser extensions that directly populate EHR fields.

API (Application Programming Interface)

A set of protocols and tools that allows different software applications to communicate with each other. In healthcare, APIs enable secure data exchange between AI scribes and EHR systems while maintaining HIPAA compliance.

HL7 (Health Level Seven)

International standards for the exchange, integration, sharing, and retrieval of electronic health information. These standards ensure that different healthcare systems can communicate effectively and securely.

Billing & Coding Terms

ICD-10 Coding

International Classification of Diseases, 10th Revision - standardized diagnostic codes required for insurance billing. These alphanumeric codes describe diseases, injuries, and symptoms. Doctora's AI automatically suggests appropriate ICD-10 codes based on documented findings, reducing claim denials and improving reimbursement rates.

CPT Codes

Current Procedural Terminology codes that describe medical services and procedures performed during patient encounters. These five-digit codes are essential for billing insurance companies and determining reimbursement amounts. Doctora helps optimize CPT code selection for maximum legitimate reimbursement.

Medical Necessity

Healthcare services or supplies needed to diagnose or treat an illness, injury, condition, disease, or its symptoms that meet accepted standards of medicine. Proper documentation of medical necessity is crucial for insurance reimbursement.

Modifier Codes

Two-digit codes appended to CPT codes that provide additional information about the service performed. They indicate special circumstances without changing the definition of the base code, such as bilateral procedures or multiple procedures.

Compliance & Security Terms

HIPAA Compliance

Adherence to the Health Insurance Portability and Accountability Act, which sets national standards for protecting patient health information privacy and security. Doctora maintains HIPAA compliance through encryption, access controls, audit trails, and signed Business Associate Agreements (BAAs).

Business Associate Agreement (BAA)

A legal contract between a healthcare provider and a third-party vendor that handles protected health information (PHI). The BAA ensures that the vendor will appropriately safeguard PHI according to HIPAA requirements.

Protected Health Information (PHI)

Any health information that can be tied to an individual, including demographic data, medical histories, test results, insurance information, and other data used to identify a patient or provide healthcare services.

End-to-End Encryption

A security method where data is encrypted on the sender's device and only decrypted on the recipient's device, preventing anyone in between from accessing the information. This ensures patient data remains secure during transmission and storage.

Optometry-Specific Terms

PERRLA

Pupils Equal, Round, Reactive to Light and Accommodation - a common acronym used in eye examinations to document normal pupil function. Doctora's AI recognizes this and similar optometry abbreviations automatically.

Slit Lamp Examination

A microscopic examination of the anterior segment of the eye, including the eyelids, conjunctiva, cornea, iris, lens, and anterior chamber. Documentation includes detailed findings for each structure examined.

Fundus Examination

Examination of the back of the eye including the retina, optic disc, macula, and blood vessels. Documentation includes C/D ratio, vessel appearance, macular health, and peripheral retinal findings.

Visual Acuity

A measure of the eye's ability to distinguish shapes and details at a given distance. Documented as fractions (e.g., 20/20) for distance and near vision, with and without correction. AI scribes must accurately capture these measurements from spoken documentation.