chap 25

what is health information management (HIM)?

acquiring, managing, analyzing, and protecting patient health infromation

what is electronic health record (EHR)?

a secure digital record shared across healthcare organizations

what is the master patient index (MPI)?

database linking patient encounters through a unique patient identifier

what is the purpose of an H&P

documents the patient’s baseline history and physical condition

what is the chief complaint (CC)?

the patients main reason for seeking healthcare

what is the history of present illness (HPI)?

chronological details of current symptoms, onset, duration, and severity

what is past medical history (PMH)?

the patient’s previously existing medical conditions

what is a review of systems (ROS)?

a clinician’s systematic review of the patient’s organ system

what is an operative report?

surgeon’s documentation of the procedure, findings, and techniques

what is a patient portal?

secure online access to records, results, billing, and appointments

what is revenue cycle management (RCM)?

financial tracking from patient registration through final reimbursement

what is medical necessity?

clincal justification that a procedure is reasonable and necessary

what is ICM-10-CM used for?

coding diagnoses and symptoms; why an exam was performed

what is CPT used for?

coding procedures and medical services; what was performed

what does HIPPA privacy rule govern?

access, use, and disclosure of protected health information

what does HIPPA security rule protect?

electronic PHI using administrative, physical, and technical safeguards

what is the minimum necessary rule

access only the PHI needed for your specific job duties

what is interoperability?

different systems exchanging and interpreting information seamlessly

what is health information exchange (HIE)?

secure sharing of record between different healthcare organizations

what is DICOM?

standard for formatting, storing, and transmitting medical images

what is HL7?

standard for exchanging clinical orders, scheduling, and demographic data

what is HIS?

hospital information system; hospital-wide registration, billing, and records

what is RIS?

radiology information system; imaging schedules, workflows, and reports

what is PACS?

picture archiving and communications system; stores and displays images

a tech checks eGFR and creatinine before contrast. which resource?

EHR : provides access to laboratory results needed for imaging safety

a radiographer accesses a neighbor’s chart out of curiosity. violation?

HIPAA privacy rule : unauthorized access to PHI

a hospital requires staff cybersecurity training. safeguard type?

administrative safeguard

a hospital installs locked doors around its server room. Safeguard?

physical safeguard

a radiographer locks a workstation before leaving. Safeguard type?

Technical safeguard

a CT scanner sends images to PACS. which communication standard?

DICOM: the standard for transmitting medical image data