Strand 6 Study Notes: Building Health Information Literacy for Medical and Dental Offices

Health Information Management (HIM)

The field that collects, organizes, protects, and uses health information to support high-quality patient care, legal requirements, billing, operations, and research.

Data

Raw facts that have not been interpreted or organized.

Information

Data that has been organized and given meaning to support a decision.

Competency

The demonstrated ability to perform tasks to an expected standard, especially in health information literacy.

Primary health data sources

Data created as a direct result of patient care.

Secondary health data sources

Data re-used for purposes beyond the immediate care encounter, often aggregated or derived from primary sources.

Electronic Medical Record (EMR)

An electronic record typically used within one organization or practice.

Electronic Health Record (EHR)

A broader electronic record intended to support sharing across different healthcare settings.

Personal Health Record (PHR)

A health record managed by the patient, containing their health information.

Clearinghouse

An entity that routes and processes electronic transactions, particularly insurance claims, between healthcare providers and payers.

Accrediting bodies

Organizations that evaluate healthcare providers against published standards for quality and safety.

Regulatory bodies

Government agencies that enforce laws and regulations affecting healthcare documentation and practices.

Medical necessity

Documentation that justifies the appropriateness of the care provided based on the patient's condition.

Audit

A review process to ensure documentation compliance and accuracy.

Corrections in documentation

Changes made to rectify errors in a record, requiring transparency and proper procedures.

Confidentiality in health information

The obligation to protect a patient's privacy and restrict access to their health information.

Timeliness in documentation

The requirement that health records must be completed within an appropriate timeframe to ensure accuracy.

Role-based access

A security measure ensuring that only authorized personnel have access to specific health records.

Documentation integrity

The accuracy, completeness, and reliability of health information documentation.

Denial management

The process of tracking and addressing claims that are denied by payers due to documentation issues.

Quality improvement

Efforts aimed at enhancing the services and outcomes of healthcare delivery.

Document retention rules

Guidelines dictating how long health records must be maintained by healthcare providers.

Performance measures

Metrics derived from patient records for assessing the quality of care.

Billing interfaces

Systems that link clinical documentation to financial transactions for reimbursement.

Evidence-based practice

Clinical practices based on the best available evidence to ensure effective patient care.

Informed consent documentation

Records that show a patient has agreed to treatment after understanding its risks and benefits.

Standardized terminology

Consistent use of defined medical terms to avoid ambiguity in clinical documentation.

Reimbursement requirements

Conditions that must be met in documentation for insurance providers to reimburse for services rendered.