Glossary: medical records AI terms, defined plainly
Answer in brief: 20 terms that come up when you compare medical records AI, each defined in 1 or 2 sentences, grouped by the job they belong to. Terms are linked from the pages where they first appear.
Limits: Vendor facts come from each vendor's own website (1 from trade press), read 2026-11-12. We haven't run every product, and prices change, so check the vendor before you buy.
Contract and privacy terms
- BAA (Business Associate Agreement)
- The HIPAA contract a vendor signs before it handles PHI for a covered entity. No BAA, no patient data in the tool. ChatGPT Health, for example, states it offers none.
- PHI (protected health information)
- Health information that identifies a person and is held by a covered entity or its business associate: names, dates, record numbers, and the record content tied to them.
- Covered entity
- Under HIPAA, a health care provider that bills electronically, a health plan or a clearinghouse. Physicians in practice almost always are one.
- SOC 2
- An audit report on a company's security controls. Type 2 covers how the controls worked over a period, not only on 1 day. A report you can request, not a badge.
Terms for records you create
- Ambient scribe
- Software that listens to a visit and drafts the clinical note. You review and sign the note; the scribe doesn't.
- Autonomous coding
- Software that assigns billing codes to an encounter and sends it to billing without a human coder, routing unclear cases to people. Different from code suggestions, where a human picks.
- E/M (evaluation and management)
- The family of CPT codes for office, hospital and other visits, leveled by medical decision making or time. The most common professional claim a physician group bills.
- ICD-10
- The diagnosis code set used on US claims (ICD-10-CM). Scribes such as Freed suggest these codes from the note.
- KLAS
- A research firm that rates health IT vendors from customer interviews. Vendors quote its awards; we report those as the vendor's statement.
Terms for records you gather
- TEFCA
- The Trusted Exchange Framework and Common Agreement: the federal framework for nationwide exchange of health records between networks.
- QHIN (Qualified Health Information Network)
- A network approved to exchange records under TEFCA. Retrieval vendors such as Health Gorilla connect through them.
- Carequality
- An interoperability framework that lets participating networks and EHRs query each other for a patient's records. Abstractive Health retrieves through it.
- FHIR
- A standard format and API for health data. FHIR R4 is the version most patient-access apps, including Fasten Health, use.
- Release of information
- The process, often outsourced, by which a custodian copies and sends records in answer to an authorized request. The road legal and disability files travel.
Terms for records you read
- Page citation
- A pointer from a line of AI output to the source page it came from, so you can open the page and check. The single most useful feature in an outside file summary.
- Medical chronology
- A table of encounters in date order, 1 row per event, with the provider, the finding and the source page.
- Deduplication
- Finding pages that appear more than once in a record set, such as the same report sent by 2 providers. Some tools bill duplicates; Medrecords AI (ours) doesn't.
- Pre-visit summary
- A short summary of your own patient's chart before an encounter, usually inside the EHR. A different job from summarizing an outside file for a review.
Terms for records patients hold
- Patient portal
- The provider's website or app where patients see results, notes and messages, such as Epic MyChart.
- MCP (Model Context Protocol)
- An open protocol that connects AI assistants to outside data. athenahealth's athenaPatient MCP lets a patient connect their records to Claude.