- Legal health record
- The documentation an organization formally declares as its official business record, generated and released in response to legal requests.
- Designated record set
- The HIPAA-defined group of records a covered entity uses to make decisions about an individual, including medical and billing records.
- Master Patient Index (MPI)
- A permanent database that links each patient to a single unique identifier across all encounters and systems.
- Duplicate (MPI error)
- One patient assigned two or more medical record numbers, creating separate records for the same person.
- Overlay (MPI error)
- One record number mistakenly holding the data of two different patients — a serious patient-safety error.
- Overlap (MPI error)
- A patient with different identifiers in two separate facilities within an enterprise master patient index.
- UHDDS
- Uniform Hospital Discharge Data Set — the minimum core data elements collected on every hospital inpatient discharge.
- UACDS
- Uniform Ambulatory Care Data Set — recommended minimum data elements for ambulatory (outpatient) care encounters.
- MDS
- Minimum Data Set — the standardized assessment data set used in long-term care (skilled nursing) facilities.
- OASIS
- Outcome and Assessment Information Set — the standardized data set used in home health care.
- Principal diagnosis
- The condition established after study to be chiefly responsible for the patient's admission to the hospital (UHDDS definition).
- Secondary diagnosis
- An additional condition that coexists at admission or develops during the stay and affects patient care.
- Quantitative analysis
- A review of the record for completeness — checking that all required reports, signatures, and entries are present.
- Qualitative analysis
- A review of record content for quality and consistency — whether documentation supports the diagnoses and care provided.
- Delinquent record
- An incomplete health record that remains unfinished beyond the time limit set in medical-staff rules and regulations.
- Deficiency
- A missing element in a health record, such as an absent signature, report, or required entry.
- Concurrent analysis
- Review of the record for deficiencies while the patient is still being treated, allowing real-time correction.
- Retrospective analysis
- Review of the record for deficiencies after the patient has been discharged.
- Source-oriented record
- A paper record organized by the department or source that created each document (e.g., all lab reports together).
- Problem-oriented record
- A record organized around a problem list, with SOAP-format progress notes tied to numbered problems.
- SOAP note
- A progress-note format with Subjective, Objective, Assessment, and Plan components.
- Problem list
- A summary list of a patient's significant illnesses, conditions, and procedures maintained over time.
- History and physical (H&P)
- A required report documenting the patient's history and physical exam, generally completed within 24 hours of admission.
- Discharge summary
- A report summarizing the hospital stay, including the reason for admission, course of care, and discharge instructions.
- Operative report
- A report describing a surgical procedure, dictated immediately after surgery by the responsible surgeon.
- Consultation report
- The opinion of a physician other than the attending, requested to evaluate a specific problem.
- Advance directive
- A document stating a patient's wishes for medical care if they become unable to decide, such as a living will.
- Informed consent
- Documentation that a patient was told the risks, benefits, and alternatives of a procedure and agreed to it.
- Authentication
- Confirming the authorship of an entry, typically by signature, initials, or a unique electronic credential.
- Electronic signature
- A method of authenticating an entry electronically, such as a password-protected sign-off in the EHR.
- Countersignature
- A signature by a supervising provider verifying an entry made by a resident, student, or other staff member.
- Standardization of forms
- Controlling the design, content, and approval of forms so data are captured consistently across the organization.
- Forms committee
- A group that reviews, approves, and controls the creation and revision of health record forms.
- Document control
- The process of creating, revising, approving, and standardizing forms and documents in a controlled way.
- Data dictionary
- A reference that defines each data element's meaning, format, and allowable values to ensure consistent use.
- Metadata
- Data about data — descriptive information such as who created an entry, when, and from which system.
- Data integrity
- Assurance that data are accurate, complete, and unaltered throughout their lifecycle.
- Information governance
- An organization-wide framework for managing information to support compliance, value, and risk control.
- Data governance
- The control of data assets — defining ownership, standards, and accountability for data quality.
- Secondary data source
- Data taken from the primary record and reorganized for another purpose, such as a registry or index.
- Primary data source
- The health record itself, created during direct patient care.
- Disease index
- A list of diseases and conditions, organized by ICD code, used to locate records for study or reporting.
- Operation index
- A list of procedures performed, organized by code, used to retrieve cases for review or research.
- Physician index
- A list of cases organized by attending or operating physician.
- Cancer registry
- A secondary data system that tracks cancer cases, treatment, and outcomes for reporting and research.
- Trauma registry
- A database of trauma cases used to evaluate and improve trauma care and outcomes.
- Birth certificate
- A vital record documenting a birth; HIM staff often help ensure timely, accurate completion.
- Accuracy (data quality)
- A data-quality characteristic meaning the data are correct, valid, and free of error.
- Completeness (data quality)
- A data-quality characteristic meaning all required data elements are present.
- Consistency (data quality)
- A data-quality characteristic meaning data mean the same thing across systems and time.
- Currency / timeliness
- A data-quality characteristic meaning data are up to date and recorded near the time of the event.
- Granularity
- A data-quality characteristic meaning data are captured at the right level of detail for their use.
- Relevancy
- A data-quality characteristic meaning the data collected are meaningful for their intended purpose.
- Retention schedule
- A policy specifying how long each type of record must be kept before it can be destroyed.
- Record destruction
- The secure, irreversible disposal of records after the retention period, documented per policy.
- Legal hold
- A directive to preserve records relevant to anticipated or pending litigation, suspending normal destruction.
- Joint Commission
- An accrediting body whose standards (e.g., for documentation timeliness) hospitals must meet.
- Conditions of Participation
- CMS requirements a facility must meet to be reimbursed by Medicare and Medicaid.
- Do-not-use abbreviation list
- A list of error-prone abbreviations (e.g., U for unit) that must not be used in documentation.
- Amendment
- A change to an existing health-record entry that keeps the original entry visible and intact.
- Late entry
- Documentation added after the time of service, labeled and dated as a late entry without altering prior notes.
- Addendum
- Additional information appended to a record entry to clarify or complete prior documentation.
- Version control
- Tracking successive versions of a document or template so the correct, current one is in use.
- Chart conversion
- Migrating documentation from a paper record into the electronic health record system.
- Hybrid record
- A health record that exists partly on paper and partly in electronic systems.
- Census
- The number of inpatients present in a facility at a given time, typically counted at midnight.
- Health record number
- The unique number assigned to a patient's record, often via a unit numbering system.
- Unit numbering system
- A filing system in which a patient keeps one record number for all visits, consolidating documentation.
- Serial numbering system
- A system in which a patient receives a new record number at each admission.
- Serial-unit numbering
- A system that issues a new number each visit but brings prior records forward to the latest number.
- Terminal-digit filing
- A paper-filing method that orders records by the last digits of the record number to distribute filing evenly.
- Chart deficiency system
- A tracking system that flags incomplete charts and routes them to providers for completion.
- Documentation guidelines
- Rules — from coding guidelines, CMS, the Joint Commission, and law — that govern record content and quality.
- Legal health record matrix
- A document listing each source system and whether its output is part of the legal health record.
- Designated record set vs LHR
- The designated record set is broader (decision-making records); the legal health record is the version released for legal requests.
- Patient-generated data
- Health data created by the patient (e.g., home readings); generally not part of the legal health record.
- EHR (electronic health record)
- A digital, longitudinal record of a patient's health information maintained by providers over time.
- PHR (personal health record)
- A health record maintained and controlled by the patient, separate from the provider's legal record.
- Structured data
- Data stored in defined fields with controlled values, allowing easy search and analysis.
- Unstructured data
- Free-text or narrative data (e.g., a dictated note) not stored in discrete fields.
- Indexing
- Organizing records or data so specific cases can be located, such as by disease, operation, or physician.
- Registry
- An organized secondary data system that collects, stores, and reports cases of a defined type (e.g., cancer).
- Core data elements
- The standardized minimum data items, such as those defined by the UHDDS, collected for each encounter.
- Health information governance role
- HIM's responsibility to maintain accurate, complete, secure, and properly governed health information.
- HIPAA
- Health Insurance Portability and Accountability Act — sets national standards to protect health information.
- Privacy Rule
- The HIPAA rule governing the use and disclosure of protected health information (PHI).
- Security Rule
- The HIPAA rule that protects electronic PHI through administrative, physical, and technical safeguards.
- Protected health information (PHI)
- Individually identifiable health information held or transmitted by a covered entity in any form.
- ePHI
- Electronic protected health information — PHI created, stored, or transmitted electronically.
- Minimum necessary
- Using or disclosing only the least amount of PHI needed to accomplish the intended purpose.
- Treatment exception (minimum necessary)
- Disclosures for treatment are exempt from the minimum-necessary standard.
- TPO
- Treatment, payment, and health-care operations — uses and disclosures of PHI permitted without authorization.
- Authorization
- A patient's signed permission to use or disclose PHI for a purpose not otherwise permitted by HIPAA.
- Accounting of disclosures
- A patient's right to a list of certain disclosures of their PHI, with date, recipient, description, and purpose.
- Right of access
- A patient's right to inspect and obtain a copy of their PHI in the designated record set.
- Notice of Privacy Practices
- A document informing patients how their PHI may be used and disclosed and of their privacy rights.
- Covered entity
- A health plan, health-care clearinghouse, or provider that transmits health information electronically.
- Business associate
- A person or entity that performs functions involving PHI on behalf of a covered entity.
- Business associate agreement
- A contract requiring a business associate to safeguard PHI as HIPAA requires.
- Release of information (ROI)
- The process of disclosing PHI to authorized requesters according to law and policy.
- Valid authorization
- An authorization that is specific, dated, signed, and not expired, naming the information and recipient.
- Personal representative
- A person with legal authority to act for a patient (e.g., guardian, healthcare proxy) regarding PHI.
- Psychotherapy notes
- Specially protected notes that generally require separate, specific authorization to disclose.
- Super-protected information
- Categories such as substance use, HIV, and mental health that have heightened disclosure restrictions.
- 42 CFR Part 2
- Federal rules giving extra confidentiality protection to substance-use-disorder treatment records.
- Breach (HIPAA)
- An impermissible use or disclosure of PHI that compromises its security or privacy.
- Breach notification
- The requirement to notify affected individuals (and others) after a breach of unsecured PHI.
- HITECH Act
- A law that promoted EHR adoption and strengthened HIPAA enforcement and breach notification.
- Privacy audit
- A review of who accessed PHI and whether the access was appropriate and authorized.
- Security audit
- A review of safeguards and system activity to verify ePHI is protected against unauthorized access.
- Audit trail
- An automatic log of system activity recording who accessed what data, when, and what action they took.
- Access control
- Technical safeguards that limit system access to authorized users (e.g., unique IDs, role-based access).
- Role-based access
- Granting users only the access their job role requires — a minimum-necessary safeguard.
- Encryption
- Converting data into a coded form so only authorized parties can read it, protecting ePHI.
- Authentication (security)
- Verifying a user's identity before granting access, typically via a unique password or credential.
- Firewall
- A technical safeguard that controls network traffic to block unauthorized access to systems.
- Confidentiality
- The obligation to keep PHI private and disclose it only to authorized parties.
- Integrity (security)
- Assurance that ePHI is not improperly altered or destroyed.
- Availability (security)
- Assurance that ePHI is accessible and usable by authorized persons when needed.
- Risk analysis (Security Rule)
- A required assessment of risks and vulnerabilities to ePHI to guide safeguards.
- Sanction policy
- A policy specifying penalties for workforce members who violate privacy or security rules.
- Workforce training
- Required education of staff on privacy and security policies and their responsibilities.
- Disclosure log
- A record of accountable disclosures used to produce a patient's accounting of disclosures.
- Subpoena
- A legal order to produce records or testimony; HIM verifies validity before releasing PHI.
- Court order
- A judge's directive that may compel disclosure of PHI even without patient authorization.
- Redisclosure prohibition
- A notice that information released may not be further disclosed without authorization.
- Case mix index (CMI)
- The average DRG relative weight for a group of inpatients — sum of DRG weights ÷ number of discharges.
- CMI interpretation
- A higher CMI reflects a more resource-intensive, higher-acuity patient population.
- Gross death rate
- (Number of inpatient deaths ÷ total discharges, including deaths) × 100, for a period.
- Net death rate
- Death rate excluding deaths occurring less than 48 hours after admission.
- Gross autopsy rate
- (Inpatient autopsies ÷ total inpatient deaths) × 100.
- Net autopsy rate
- Autopsy rate excluding bodies not available for autopsy (e.g., released to the coroner).
- Hospital autopsy rate
- Autopsies on hospital patients ÷ deaths of hospital patients whose bodies were available, × 100.
- Hospital infection rate
- (Number of hospital-acquired infections ÷ total discharges) × 100, for a period.
- Postoperative infection rate
- (Infections in clean surgical cases ÷ number of surgical operations) × 100.
- Cesarean-section rate
- (Number of C-section deliveries ÷ total deliveries) × 100.
- Average daily census
- Total inpatient service days for a period ÷ number of days in the period.
- Average length of stay (ALOS)
- Total length-of-stay days (discharge days) for discharges ÷ number of discharges.
- Length of stay (LOS)
- The number of days from admission to discharge for a single patient (admission and discharge counted as one day).
- Inpatient service day
- A unit measuring the services received by one inpatient in one 24-hour period.
- Bed occupancy rate
- (Inpatient service days ÷ available bed days) × 100, measuring bed utilization.
- Bed turnover rate
- The number of times a bed changes occupants in a period, indicating bed use efficiency.
- Abstracting
- Extracting and recording relevant data elements from the record into a database or registry.
- Data analytics
- Examining data to find patterns and produce information that supports decisions.
- Descriptive statistics
- Statistics that summarize data, such as counts, percentages, means, and rates.
- Mean
- The arithmetic average — sum of values ÷ number of values.
- Median
- The middle value when data are ordered; resistant to extreme values.
- Mode
- The most frequently occurring value in a data set.
- Range
- The difference between the highest and lowest values in a data set.
- Rate
- A measure comparing the number of times an event occurred to the number of times it could have occurred.
- Ratio
- A comparison of two quantities, such as the ratio of staff to patients.
- Proportion
- A type of ratio in which the numerator is included in the denominator.
- Percentage
- A proportion expressed per 100.
- Nominal data
- Categorical data with no inherent order, such as gender or blood type.
- Ordinal data
- Categorical data with a meaningful order but unequal intervals, such as pain scales.
- Continuous data
- Numeric data measured on a scale with meaningful intervals, such as weight or temperature.
- Bar graph
- A chart that displays categorical data using rectangular bars.
- Histogram
- A chart that displays the frequency distribution of continuous data using adjacent bars.
- Pie chart
- A circular chart showing parts of a whole as proportional slices.
- Line graph
- A chart that displays trends over time using connected points.
- Core measures
- Standardized performance measures used to assess and report quality of care.
- Registry reporting
- Submitting abstracted data to a registry (e.g., cancer) for tracking and analysis.
- Disease registry
- A system that collects and maintains data on patients with a specific condition for study and reporting.
- Benchmarking
- Comparing performance metrics against an internal or external standard to identify improvement.
- Productivity measure
- A metric of work output, such as charts coded or records analyzed per hour.
- Delinquency rate
- The proportion of incomplete records that remain delinquent past the allowed time limit.
- Data visualization
- Presenting data graphically (charts, dashboards) to communicate findings clearly.
- Dashboard
- A visual display of key metrics used to monitor performance at a glance.
- Aggregate data
- Summarized data combined from many records, with individual identities removed.
- Trend analysis
- Examining data over time to detect direction, patterns, or changes.
- Resource allocation
- Distributing staff, time, and budget based on workload and statistical analysis.
- Statistic denominator
- For most hospital rates, the denominator is the number of discharges in the period.
- Frequency distribution
- A table showing how often each value or category occurs in a data set.
- Standard deviation
- A measure of how spread out values are around the mean.
- Outlier
- A data value far from the others that can distort the mean and may need review.
- Real-time analytics
- Analysis of data as it is generated, supporting immediate operational decisions.
- Revenue cycle
- The financial process from patient scheduling through final payment for services.
- Discharged Not Final Billed (DNFB)
- Accounts for discharged patients whose claims have not been sent, often due to incomplete coding.
- Charge capture
- Recording the services and supplies provided so they can be billed.
- Chargemaster (CDM)
- A master list of all billable items, services, and their charges used to generate claims.
- Clinician query
- A request asking a provider to clarify ambiguous, incomplete, or conflicting documentation.
- Compliant query
- A non-leading query supported by clinical indicators that does not suggest a diagnosis to raise payment.
- Leading query
- A non-compliant query that steers the provider toward a specific, usually higher-paying answer.
- Utilization review
- Evaluating the medical necessity, appropriateness, and level of care of services.
- Medical necessity
- The principle that a service is reasonable and necessary; diagnosis codes must support the service.
- Denial
- A payer's refusal to pay a claim, in whole or part, often for coding or documentation reasons.
- Denial management
- The process of analyzing, appealing, and preventing claim denials to recover revenue.
- Appeal
- A formal request asking a payer to reconsider a denied claim, supported by documentation.
- Coding audit
- A review of assigned codes against documentation to verify accuracy and compliance.
- ICD-10-CM
- The U.S. code set for reporting diagnoses in all health-care settings.
- ICD-10-PCS
- The 7-character code set used to report inpatient hospital procedures.
- CPT
- Current Procedural Terminology — codes for physician and outpatient procedures and services.
- HCPCS Level II
- Codes for supplies, drugs, equipment, and services not covered by CPT.
- MS-DRG
- Medicare Severity Diagnosis-Related Group — the inpatient classification paying a fixed amount per admission.
- APC
- Ambulatory Payment Classification — the payment unit under the hospital outpatient prospective payment system.
- IPPS
- Inpatient Prospective Payment System — Medicare's method of paying acute hospitals per MS-DRG.
- OPPS
- Outpatient Prospective Payment System — Medicare's method of paying hospital outpatient services via APCs.
- DRG vs APC
- DRGs pay for inpatient admissions; APCs pay for hospital outpatient services.
- Principal diagnosis (coding)
- The condition after study chiefly responsible for admission; sequenced first for inpatients.
- First-listed diagnosis
- In outpatient coding, the reason chiefly responsible for the services, sequenced first.
- Sequencing
- Listing codes in the correct order — principal/first-listed diagnosis first, then secondaries.
- MCC
- Major complication or comorbidity — a secondary condition that can shift a case to a higher-paying DRG.
- CC
- Complication or comorbidity — a secondary condition that raises the DRG tier less than an MCC.
- POA indicator
- Present on Admission indicator (Y, N, U, W) reported with each inpatient diagnosis.
- Modifier
- A two-character CPT/HCPCS addition giving detail such as bilateral, repeat, or distinct service.
- NCCI edits
- National Correct Coding Initiative edits that block improper code pairs and unbundling.
- Unbundling
- Reporting components of a service separately to gain higher payment when one code should be used.
- Upcoding
- Assigning a more severe or expensive code than the documentation supports — fraud.
- Encoder
- Software that helps coders find and assign correct codes.
- Grouper
- Software that classifies coded cases into a payment group such as an MS-DRG or APC.
- Computer-assisted coding (CAC)
- Software that suggests codes via natural-language processing; a coder validates every code.
- Clinical documentation integrity (CDI)
- Efforts to ensure the record accurately and completely reflects the patient's clinical status.
- Clean claim
- A claim with no errors that can be processed and paid without additional information.
- Remittance advice
- A payer document explaining how a claim was paid, adjusted, or denied.
- Explanation of benefits (EOB)
- A statement to the patient explaining what the payer covered and what the patient owes.
- Coding turnaround time
- The time from discharge to completed coding — a key HIM standard affecting DNFB.
- Discharge planning
- Coordinating a patient's post-discharge care needs before they leave the facility.
- Case mix
- The types and severity of cases a facility treats, reflected in coding and reimbursement.
- Coding compliance
- Adherence to official coding guidelines and rules to ensure accurate, ethical coding.
- Coding query policy
- A policy defining when and how coders query providers in a compliant, non-leading way.
- Fraud
- Knowingly submitting false claims for payment, such as billing for services not provided.
- Abuse
- Practices inconsistent with sound fiscal or medical practice that result in unnecessary cost.
- Recovery Audit Contractor (RAC)
- A CMS contractor that reviews claims to identify and recover improper payments.
- Coding accuracy rate
- The proportion of audited codes found correct — a core coding-quality metric.
- Medical necessity edit
- An edit that checks whether the diagnosis supports the billed service.
- Charge reconciliation
- Confirming that all services provided were captured and billed.
- Compliance program
- An organized effort to prevent, detect, and correct violations of laws, regulations, and policies.
- Risk assessment
- Identifying and ranking where an operation could fail to meet requirements so resources target the highest risks.
- Quality assessment
- Systematic evaluation of services or processes against standards to find improvement opportunities.
- Quality improvement (QI)
- An ongoing process to improve outcomes and processes, often using PDCA cycles.
- PDCA cycle
- Plan-Do-Check-Act — a structured method for testing and implementing improvements.
- Patient Safety Indicators (PSIs)
- AHRQ measures that screen coded data for potentially preventable in-hospital complications.
- Hospital-Acquired Condition (HAC)
- A reasonably preventable condition acquired during the stay; if not POA, it can reduce payment.
- Never event
- A serious, largely preventable adverse event that should never occur (e.g., wrong-site surgery).
- Sentinel event
- An unexpected occurrence involving death or serious harm that triggers immediate investigation.
- Root cause analysis
- A structured process to find the underlying cause of an adverse event and prevent recurrence.
- AHIMA Standards of Ethical Coding
- Principles requiring accurate, honest coding that reflects documentation, never upcoding.
- Code of ethics
- Professional principles guiding honest, accountable conduct in HIM practice.
- Corrective action plan
- A documented plan to fix identified compliance problems and prevent recurrence.
- Internal audit
- A self-review of processes and records to detect compliance issues before external review.
- External audit
- A review by an outside party, such as a payer or accreditor, of compliance and accuracy.
- Regulatory monitoring
- Tracking changes in laws and regulations to implement them timely and accurately.
- Conditions of Participation (compliance)
- CMS requirements a facility must meet to participate in Medicare and Medicaid.
- Accreditation
- Voluntary review by an external body (e.g., the Joint Commission) confirming standards are met.
- Licensure
- A state requirement permitting a facility or individual to operate or practice.
- Certification (facility)
- Confirmation that a provider meets federal standards to bill Medicare and Medicaid.
- Standard of care
- The level of care a reasonably prudent provider would deliver under similar circumstances.
- HIM standards
- Performance benchmarks for HIM functions such as chart completion, coding accuracy, and ROI turnaround.
- Chart completion standard
- A benchmark for how quickly and completely records must be finished after discharge.
- Coding accuracy standard
- A benchmark for the percentage of codes that must be correct on audit.
- ROI turnaround standard
- A benchmark for how quickly release-of-information requests are completed.
- Performance improvement
- Activities aimed at raising the quality and efficiency of processes and outcomes.
- Compliance officer
- The individual responsible for overseeing an organization's compliance program.
- Whistleblower protection
- Legal protection for employees who report fraud or noncompliance in good faith.
- False Claims Act
- A federal law imposing liability for knowingly submitting false claims to the government.
- OIG Work Plan
- The Office of Inspector General's annual list of compliance focus areas and audits.
- Compliance training
- Educating staff on rules and policies so they can perform work compliantly.
- Incident report
- A document recording an unexpected event or near miss; it is not part of the legal health record.
- Quality indicator
- A measurable element of performance used to monitor and improve care quality.
- Variance / occurrence
- A deviation from expected process or outcome that is tracked for quality and risk.
- Peer review
- Evaluation of a provider's care by professional peers to assess quality.
- Risk management
- Activities that identify and reduce the chance of loss, injury, or liability.
- Continuous monitoring
- Ongoing review of metrics and audits to keep operations within compliance.
- Policy on noncompliance reporting
- A defined channel for reporting suspected violations, such as a hotline.
- Data quality program
- Structured efforts to monitor and improve the accuracy and completeness of data.
- Documentation improvement
- Refining documentation practices so records support coding, quality, and compliance.
- Regulatory implementation
- Putting a new rule into operational practice through updated policies and training.
- Audit sampling
- Selecting a representative subset of records to review for accuracy or compliance.
- Compliance risk areas
- Common exposure points such as coding errors, privacy breaches, and billing mistakes.
- Quality reporting program
- A program (e.g., Hospital IQR) requiring submission of quality data, often tied to payment.
- Process measure
- A quality measure of whether a recommended action was performed (e.g., aspirin on arrival).
- Outcome measure
- A quality measure of the result of care, such as mortality or readmission rate.
- Policy
- A high-level statement of what an organization will do and why — its rule on an issue.
- Procedure
- The step-by-step actions staff follow to carry out a policy.
- Policy vs procedure
- A policy states what and why; a procedure states how, step by step.
- HIM education
- Training clinicians and staff on documentation, content, privacy, and HIM laws and regulations.
- Interoperability
- The ability of different systems to exchange and meaningfully use health data.
- Promoting Interoperability
- CMS programs (formerly Meaningful Use) encouraging EHR adoption and data exchange.
- Meaningful Use
- The earlier federal program promoting effective EHR use to improve care.
- Health information exchange (HIE)
- The electronic sharing of health information among organizations within a region or system.
- Standards (interoperability)
- Agreed formats and code sets (e.g., HL7, ICD-10) that let systems exchange data.
- HL7
- A standard for exchanging clinical and administrative health data between systems.
- Process review
- Examining an existing HIM process to find inefficiencies and improvement opportunities.
- Workflow
- The sequence of steps and handoffs by which work moves through an HIM operation.
- Workflow redesign
- Restructuring steps and handoffs to improve efficiency and quality.
- Standard operating procedure
- A documented routine for performing a recurring task consistently.
- Change management
- Guiding people and processes through a transition, such as an EHR upgrade.
- Technical expertise (HIM)
- Specialized HIM knowledge applied to support systems, data, and compliance.
- Collaboration
- Working with other departments (IT, billing, clinical) to support shared goals like interoperability.
- Standards for HIM functions
- Established benchmarks for chart completion, coding accuracy, ROI, and workflow.
- Mentoring
- Guiding and developing less-experienced staff to build skills and competence.
- Productivity standard
- An expected output level for a role, used to plan staffing and measure performance.
- Staffing plan
- A plan matching staff numbers and skills to the department's workload.
- Job description
- A document defining a position's duties, responsibilities, and required qualifications.
- Training program
- An organized set of activities to build staff knowledge and skills.
- Performance feedback
- Communicating how an employee's work compares to standards to support improvement.
- Project management
- Planning, organizing, and overseeing tasks to complete a defined goal on time.
- Vendor coordination
- Working with software or service vendors to support HIM systems and goals.
- Continuing education
- Ongoing learning required to maintain a credential and current knowledge.
- Subject-matter expert
- A person with deep expertise in a domain who advises on decisions and problems.
