Strand 6: Health Information Management in Medical & Dental Offices

Health Record

An organized collection of information about a patient’s health history and care over time.

Clinical Continuity

The ability for healthcare providers to understand the sequence of care when treating a patient.

Patient Safety

The practice of reducing preventable errors through accurate and complete health record documentation.

Legal Documentation

A formal account of services provided, often used in disputes as key evidence.

Billing and Reimbursement

The process of documenting services rendered to ensure accurate claims and payment.

Paper Record

A physical chart containing patient information.

EHR

Electronic Health Record, a digital system for storing and managing patient data.

Legal Health Record

The official version of the health record designated by policy, which may not include all elements.

Patient Identification

The process of recording patient demographic information.

Insurance Information

Details about patient insurance coverage necessary for billing.

Medical History

A record of past medical and surgical history related to patient care.

Medication List

A compilation of all medications currently prescribed to the patient.

Problem List

A list of active and relevant historical diagnoses for the patient.

Visit Documentation

Records of chief complaints, history, examinations, assessments, and treatment plans from patient visits.

Care Coordination Documentation

Records of referrals, follow-ups, and tracking related to patient care.

Health Information Management (HIM)

The practice of managing health information to support patient care.

Create/Collect Phase

The first step in the health record lifecycle, involving registration and history collection.

Use Phase

The stage of the record lifecycle where documentation of encounters occurs.

Maintain Phase

Keeping health records updated, correcting errors, and managing external information.

Disclose Phase

Sharing patient information for permitted purposes or authorized requests.

Store/Rentain Phase

Keeping health records secure for the legally defined duration.

Dispose Phase

The safe destruction of health records once retention requirements are met.

Good Documentation

Accurate, complete, timely, legible, understandable, and signed recording of patient information.

SOAP Note Format

A structured format for documentation: Subjective, Objective, Assessment, Plan.

Subjective Content

Information based on patient-reported symptoms and experiences.

Objective Content

Documented facts, such as lab results and clinical findings.

Informed Consent

The process of explaining treatment risks and benefits so the patient can make an informed choice.

Audit Trail

A record that captures changes and access in electronic health records.

Protected Health Information (PHI)

Individually identifiable health information related to a patient's health or payment.

Minimum Necessary Principle

Accessing or sharing only the amount of information necessary to perform a job.

Patient Rights

Patients have the right to access, amend, and restrict their health information.

Business Associate

A person or entity that needs access to PHI to perform services on behalf of a covered entity.

Chain of Custody

Documentation of the release and access of health records to protect compliance.

Record Retention

The legal requirement to keep health records for a specified period.

Secure Destruction

Disposing of records in a manner that prevents reconstruction or retrieval.

Data Integrity

Ensuring health data remain accurate, consistent, and reliable over time.

Coding Systems

Standardized codes used to communicate healthcare services for billing and reporting.

ICD-10-CM

A coding system for diagnosis classification used for reporting conditions.

CPT Codes

Procedure and service codes widely used in outpatient billing.

Medical Necessity

The justification that a procedure or service is warranted based on the diagnosis.

Data Quality Problems

Issues that compromise the accuracy, completeness, and reliability of health records.

Clinical Documentation

The act of consistently recording patient information and observations.

HIM responsibilities for EHR

Includes ensuring data quality, privacy, and efficient information flow.

Patient Matching

The process of correctly identifying patients to avoid documentation errors.

Patient Portals

Secure online platforms for patients to access their information and communicate with providers.

Documentation of Follow-up

Record that confirms communication about results to a patient and outlines next steps.

Chart Control

Procedures ensuring that health records are tracked, complete, and available.

Indexing and Retrieval Practices

Methods used to label and locate information efficiently in health records.

Handling Incoming Information

Process of verifying, reviewing, and appropriately integrating new information into a record.