Strand 6 — Health Information Management (HIM): Learning Notes

Health Information Management (HIM)

The collection, organization, protection, and use of health information to support patient care and meet legal requirements.

Privacy

The patient's right to control how their personal information is used and shared.

Confidentiality

The ethical duty to keep patient information private.

Protected Health Information (PHI)

Individually identifiable health information related to a person's health, healthcare, or payment for healthcare.

Minimum Necessary

The principle that only the minimum amount of information necessary to perform a job should be used or disclosed.

Release of Information (ROI)

The process of disclosing health information to someone outside the immediate care context.

Electronic Medical Record (EMR)

A digital record of a patient's medical history within one organization.

Electronic Health Record (EHR)

A comprehensive digital record designed to be shared across different healthcare settings.

Interoperability

The ability of different health information systems to exchange and use information.

Medical Necessity

A requirement by payers that the service provided must be reasonable and necessary for the patient's condition.

Quality Improvement (QI)

Systematic efforts to improve patient outcomes, safety, and efficiency in healthcare.

Coding

The process of translating diagnoses, procedures, and services into standardized codes.

Data Quality

The degree to which data is accurate, complete, consistent, and timely.

Health Information Exchange (HIE)

A network or approach that allows participating organizations to share health information.

Clinical Decision Support (CDS)

Tools that provide clinicians with knowledge and patient-specific info to enhance patient care.

SOAP Note

A structured documentation style that includes Subjective, Objective, Assessment, and Plan.

Health Information Technology (HIT)

The technology that facilitates the management of health information.

Documentation Standards

Guidelines that ensure the consistency and quality of health information documentation.

Data Governance

The overall management of the availability, usability, integrity, and security of data.

Health Records Lifecycle

The stages a health record goes through from creation to destruction.

Clinical Documentation Improvement (CDI)

Efforts aimed at improving the clarity and completeness of clinical documentation.

Audit Trail

A record that shows who accessed a system and what actions they took.

De-identification

The process of removing identifying information from health data so individuals cannot be readily identified.

Patient Portals

Online tools that provide patients with access to their health information and facilitate communication with providers.

Telehealth

The use of technology to deliver care and information at a distance.

Health Information Technology for Economic and Clinical Health (HITECH) Act

An act promoting the adoption and meaningful use of health information technology.

Health Data Analytics

The analysis of health data for insights to improve outcomes and efficiencies.

Legal Hold

A process that suspends the destruction of records when litigation is anticipated.

Administrative Safeguards

Policies and procedures designed to protect data and ensure compliance with regulations.

Technical Safeguards

The technology and processes used to protect health information.

Physical Safeguards

Security measures to protect physical locations and equipment that house health information.

Quality Measures

Standards used to evaluate the performance of healthcare services.

Clinical Coding

The process of translating medical services and diagnoses into codes.

Unique Patient Identifier

A distinct identifier that is used to accurately match patients to their records.

Data Validation

The process of ensuring that data is accurate and usable.

Information Lifecycle Management (ILM)

The policies and practices for managing data storage, retention, and disposal.

Consent Forms

Documents that authorize the use and sharing of a patient's personal health information.

Access Controls

Mechanisms that limit access to health information to authorized individuals only.

Workflow

The sequence of processes through which work passes in an organization.

Multi-factor Authentication

A security process that requires more than one form of verification to access information.

Standardized Terminology

A consistent use of terms to ensure clarity and interoperability in health information.

Alert Fatigue

A phenomenon where users become desensitized to frequent warnings or notifications, leading to missed alerts.

Risk Assessment

A process of identifying and evaluating potential risks to the privacy and security of health information.

Emerging Technologies

New technologies that may affect health information management practices, such as AI and machine learning.

Phishing

A fraudulent attempt to obtain sensitive information by disguising as a trustworthy source.

Data Breach

An incident where unauthorized access to health information occurs, risking confidentiality and integrity.

Patient Engagement

The involvement of patients in their own healthcare processes, decision making, and management.

Subpoena

A legal document ordered by the court requiring a person to testify or produce evidence.

Quality Metrics

Measurements that assess the quality of care provided to patients.