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health information management (HIM)
the management of patient healthcare data of all types
information technology
the processes needed to assimilate, organize, maintain, and store patient healthcare data
health informatics
a branch of health information management that uses computer systems to gather, organize, maintain, and store patient healthcare data
traditional health record
a medical chart stored and maintained in paper format
electronic medical record (EMR)
digitally stored and accessed patient records that allow real-time communication, reporting, and recordkeeping through electronic transmission; also called electronic health records (EHRs) or computer-based patient records (CPRs)
hybrid health record
a medical record that incorporates elements of paper-based records and electronic records
alphabetical filing system
a method of organizing health records according to each patient’s surname
numerical filing system
a method of organizing health records according to a unique patient identification number
alphanumeric filing system
a method of organizing health records by combining the first two letters of the patient’s surname with a numerical identifier
out guide
a card placed in a collection of paper files to indicate that a file has been removed
requisition
a written request for a health record
quality management
the process of planning, controlling, and improving the quality of a product or system
deficiency slip
a report generated to notify staff that a medical record is missing required information
index
a database that contains pertinent healthcare information that can be used for research, healthcare quality control, or statistical purposes
master patient index
the primary index used for HIM recordkeeping, which includes a unique record for each patient within a healthcare organization
physician index
a database that records the physician associated with each patient, diagnosis made, and procedure performed at a healthcare organization
registry
a database of information concerning births, deaths, admissions, and discharges
Centers for Disease Control and Prevention (CDC)
a United States government organization that seeks to promote healthy behaviors and the prevention of disease, injury, and disability
a global organization, created by the United Nations, that provides global leadership on health, health research, and health policy
cancer and trauma registries
compilations of healthcare data on different types of cancers and traumatic events
Centers for Medicare and Medicaid Services (CMS)
a United States government organization that administers the Medicare and Medicaid health insurance programs
birth certificate completion
the process of fully completing an infant’s birth certificate
statistical and research services
data analysis services provided for health information professionals who are conducting medical studies or tracking diseases
medical transcription
the process of creating a text-based medical record from a voice recording
medical coding
the process of assigning standardized codes to patient data obtained by examining medical records
medical billing
the process of generating claim forms that list diagnosis and procedure codes, charges, and patient demographic information for reimbursement purposes
health data security
the process of ensuring that medical records are unaltered, readily accessible, and used legitimately
Health Insurance Portability and Accountability Act (HIPAA)
a law governing the portability of health insurance when workers change jobs, the standards for electronic healthcare transactions, and the security and privacy of health data
Privacy Rule
a part of HIPAA that outlines standards for maintaining patient confidentiality and safeguarding financial and administrative data during electronic transfer
patient confidentiality
the right to expect that healthcare information will not be disclosed without a patient’s authorization
breach of confidentiality
disclosure of patient information without prior written consent
compliance
the process of adhering to state and federal laws
protected health information (PHI)
any information about a person’s health, healthcare, or payment for health services that can be linked to a specific patient
Department of Health and Human Services (HHS)
a United States government organization that establishes guidelines for health information management compliance
Office of the Inspector General (OIG)
investigates abuse, fraud, waste, and mismanagement within a government organization
American Health Information Management Association (AHIMA) |
a not-for-profit professional organization serving the educational, credentialing, networking, and advocacy needs of health information management (HIM) professionals
