RHIA Domain 1 Section 1

The collection of clinical and administrative information documenting a patient's healthcare services.

Health record

The organization's officially designated record used to respond to legal requests and support business and clinical needs.

Legal health record (LHR)

Records maintained by or for a covered entity that are used to make decisions about an individual and are subject to HIPAA access rights.

Designated record set (DRS)

An electronic record of health-related information that supports care across encounters and authorized users.

Electronic health record (EHR)

A health record controlled or managed by the individual rather than the healthcare organization.

Personal health record (PHR)

The required clinical, administrative, and legal information that makes up the patient record.

Health record content

Information entered into the health record to describe the patient's condition, services, treatment, and outcomes.

Documentation

Verification of the identity of the person responsible for a health record entry, often through a signature or approved electronic method.

Authentication

Identification of the individual who created or is responsible for a health record entry.

Authorship

An authorized addition or correction to a health record that preserves the integrity of the original documentation.

Amendment

A health record that is missing required documentation or signatures within the organization's established completion process.

Incomplete record

A health record that remains incomplete beyond the time frame established by organizational policy.

Delinquent record

The process of ensuring all required documentation, signatures, and reports are present and finalized.

Record completion

A legal document communicating a patient's wishes about future healthcare decisions if the patient cannot communicate them.

Advance directive

A documented plan outlining a patient's problems, goals,

interventions, and expected care or outcomes.

Care plan

Documentation generated by supporting departments or services, such as laboratory, radiology, pharmacy, or therapy.

Ancillary health record

A permanent index that identifies patients and links them to their health record numbers and encounters.

Master patient index (MPI)

A numbering method in which a patient is assigned one health record number that is reused for all encounters.

Unit numbering system

More than one patient record or identifier created for the same individual.

Duplicate record

An error in which information for one patient is incorrectly placed in another patient's record.

Overlay

An error in which one patient has more than one medical record number or identity entry within an enterprise.

Overlap

An index used to identify and link a patient's records across multiple facilities or systems within an enterprise.

Enterprise master patient index (EMPI)

A registration-admission-discharge-transfer system used to capture patient identity, encounter, and movement information.

R-ADT system

The period for which health information must be maintained according to law, regulation, accreditation, and organizational policy.

Record retention

The secure, authorized disposal of health information after retention requirements have been met.

Record destruction

Documentation showing that records or media were destroyed according to an approved process.

Certificate of destruction

A process that ensures users can identify and access the current approved version of a document or record.

Version control