Ch. 25 - Health Information Management

Health Information Management

the allied health profession built around the management of the healthcare record in its physical form, as well as the management of data and information within the medical record

Controlled Access

records the patients only needs to know

Master Patient Index

list of all of the patient visits at hospital

Electronic Medical Record

medical history at one specific place (facility or organization)

Electronic Health Record

longitudinal record from birth to death

How does radiology interface with the HIM department?

request for data, documentation issues, billing issues, electronic report storage

What is PACS?

Picture Archive Communication System, where all images go

Medical Coding

the transformation of verbal descriptions into numbers

What is ICD-10-CM indicating?

diagnoses for inpatient and outpatient

What is ICD-10-PCS indicating?

inpatient procedures

What is CPT indicating?

outpatient procedures

What is confidential patient information?

a clinical relationship between the patient and those providing health care

What is privacy?

the right of individuals to control disclosure of their personal information

What is security?

technical and procedural methods that control and manage access to confidential information

What does HIPAA stand for?

Health Insurance Portability & Accountability Act