Strand 6 — Health Information Management (HIM): Terminology, Documentation, Privacy, Coding, and Data Use

Health Information Management (HIM)

The practice of collecting, organizing, protecting, and using health information for safe, legal, and efficient care delivery.

Health record

A structured set of information documenting a patient's story over time, including care, findings, decisions, and outcomes.

Protected Health Information (PHI)

Health information that can identify a person and relates to their health status, care, or payment.

Electronic Health Information (EHI)

PHI stored or transmitted electronically, crucial for security and interoperability.

Electronic Medical Record (EMR)

A digital record within one organization, often contrasted with an EHR.

Electronic Health Record (EHR)

An electronic record emphasizing the patient's information across multiple settings.

Encounter

A specific visit or interaction between a patient and healthcare provider.

Continuity of care

The principle that patient information should accompany them to ensure consistent care.

Clinical tool

A function of the health record that supports continuity of patient care.

Legal document

A function of the health record used in investigations or legal proceedings.

Billing and coding source

A role of the health record that supports claims and reimbursement.

Quality and safety tool

A function of the health record that enables audits, reporting, and improvement.

History and Physical (H&P)

A component of the health record summarizing a patient's baseline history and examination findings.

Progress notes

Detailed entries in a health record documenting ongoing patient assessments and responses to treatment.

Medication administration record (MAR)

A record noting what medications were given to the patient and when.

Operative/procedure notes

Documentation detailing what procedures were performed, along with findings and complications.

Consent forms

Documents capturing patient permissions for procedures and disclosures.

Discharge summary

A summary of a patient's diagnoses, treatments, and instructions upon discharge.

SOAP notes

A structured documentation format comprising Subjective, Objective, Assessment, and Plan.

Subjective

Information reported by the patient regarding their symptoms and history.

Objective

Measurable observations made by the clinician during examination.

Assessment

The clinician's interpretation or diagnosis based on subjective and objective data.

Plan

The treatment and follow-up steps based on the assessment.

Minimum necessary

HIPAA principle limiting the use/disclosure of PHI to only what is essential.

Authorization

A patient's written consent for specific disclosures of health information.

Health Information Exchange (HIE)

A network or method enabling the sharing of health information across organizations.

HL7

A family of standards for the exchange of health information.

CPT (Current Procedural Terminology)

A set of codes to describe medical procedures and services.

ICD-10-CM (International Classification of Diseases, 10th Revision, Clinical Modification)

The coding system used for diagnoses across healthcare settings.

Payer

The entity responsible for covering healthcare costs (insurance company, government program).

Deductible

The amount a patient must pay before insurance coverage begins.

Claim

The bill submitted to an insurer for services rendered.

Denial

Refusal by a payer to pay all or part of a submitted claim.

Upcoding

Billing for a higher-level service than what was actually provided.

Unbundling

Billing separately for services that should be bundled together.

Incident report

Documentation of an unusual event that occurs within a healthcare setting.

Patient identifier

A unique number or code assigned to a patient for identification purposes.

Master Patient Index (MPI)

A database that helps match patient identities across records in an organization.

Data quality

Criteria ensuring that health information is fit for its intended use.

Audit trail

A record of who accessed or changed electronic health information.

Role-based access

Access restrictions based on a user's job duties.

Defensible documentation

Documentation that provides comprehensive and clear evidence of clinical decision-making.

Legal health record

The set of records released upon legal request which may vary by organization.

Designated record set

HIPAA term for records used to make decisions about individuals.

Record retention

Policies dictating how long health records must be kept.

Subpoena

A formal legal order requiring the release of records or testimony.

Fraud and abuse terminology

Key terms describing various types of billing issues that violate regulations.