Into to RAD - Ch. 25: Health Information Management

Health Information Management

what does HIM stand for

HIM

Provide quality information for quality patient care
• Complete, accurate, timely, available
– Acquires, analyzes, and protects medical information
• Data “stewards”
– Supports administrative processes
• Patient billing
• Research
• Accreditation

electronic health records

EHR stands for?

may

Radiology departments ___ have a separate file system for films/images -- PACS

radiologist

Radiology report dictated by ___

medical coding

the transformation of
verbal descriptions into numbers

Current Procedural Terminology

CPT stands for?

7

Radiology always starts with what #?

front end process

(Patient access, scheduling,
preauth, insurance
verifications, financial
counseling

middle end process

Charge capture,
chargemaster,
documentation, coding

back end process

Claims processing,
payment, follow-up,
collections, denials

confidential patient info

results from a clinical relationship
between patients and those providing health care

privacy

refers to the right of individuals to control disclosure of
their personal information

security

refers to the technical & procedural methods that control and manage access to confidential information Confidentiality, Privacy & Security

Authorization

___ Not Required for:
– Treatment, Payment, and Healthcare Operations
(TPO)
– Disclosing to the patient
– Emergency situations – professional judgment is
used

security rule

Safeguards a facility must take

privacy rule

How information can be used

electronic medical record

EMR

master patient index

a database that links patient demographic data from various sources to create a single, unified view of each patient

ancillary reports

the results from diagnostic and therapeutic services that supplement a patient's primary treatment plan

hospital information system

HIS stands for?

Radiology information system

RIS stands for?

Picture Archiving and Communication System

PACS stands for?

Computerized Physician Order Entry

CPOE stands for?

Protected Health Information

PHI stands for?