Your FREE RHIT Flashcards 2026 – 300+ Cards

The documentation an organization formally declares as its official business record, generated and released in response to legal requests.

The HIPAA-defined group of records a covered entity uses to make decisions about an individual, including medical and billing records.

A permanent database that links each patient to a single unique identifier across all encounters and systems.

One patient assigned two or more medical record numbers, creating separate records for the same person.

One record number mistakenly holding the data of two different patients — a serious patient-safety error.

A patient with different identifiers in two separate facilities within an enterprise master patient index.

Uniform Hospital Discharge Data Set — the minimum core data elements collected on every hospital inpatient discharge.

Uniform Ambulatory Care Data Set — recommended minimum data elements for ambulatory (outpatient) care encounters.

Minimum Data Set — the standardized assessment data set used in long-term care (skilled nursing) facilities.

Outcome and Assessment Information Set — the standardized data set used in home health care.

The condition established after study to be chiefly responsible for the patient's admission to the hospital (UHDDS definition).

An additional condition that coexists at admission or develops during the stay and affects patient care.

A review of the record for completeness — checking that all required reports, signatures, and entries are present.

A review of record content for quality and consistency — whether documentation supports the diagnoses and care provided.

An incomplete health record that remains unfinished beyond the time limit set in medical-staff rules and regulations.

A missing element in a health record, such as an absent signature, report, or required entry.

Review of the record for deficiencies while the patient is still being treated, allowing real-time correction.

Review of the record for deficiencies after the patient has been discharged.

A paper record organized by the department or source that created each document (e.g., all lab reports together).

A record organized around a problem list, with SOAP-format progress notes tied to numbered problems.

A progress-note format with Subjective, Objective, Assessment, and Plan components.

A summary list of a patient's significant illnesses, conditions, and procedures maintained over time.

A required report documenting the patient's history and physical exam, generally completed within 24 hours of admission.

A report summarizing the hospital stay, including the reason for admission, course of care, and discharge instructions.

A report describing a surgical procedure, dictated immediately after surgery by the responsible surgeon.

The opinion of a physician other than the attending, requested to evaluate a specific problem.

A document stating a patient's wishes for medical care if they become unable to decide, such as a living will.

Documentation that a patient was told the risks, benefits, and alternatives of a procedure and agreed to it.

Confirming the authorship of an entry, typically by signature, initials, or a unique electronic credential.

A method of authenticating an entry electronically, such as a password-protected sign-off in the EHR.

A signature by a supervising provider verifying an entry made by a resident, student, or other staff member.

Controlling the design, content, and approval of forms so data are captured consistently across the organization.

A group that reviews, approves, and controls the creation and revision of health record forms.

The process of creating, revising, approving, and standardizing forms and documents in a controlled way.

A reference that defines each data element's meaning, format, and allowable values to ensure consistent use.

Data about data — descriptive information such as who created an entry, when, and from which system.

Assurance that data are accurate, complete, and unaltered throughout their lifecycle.

An organization-wide framework for managing information to support compliance, value, and risk control.

The control of data assets — defining ownership, standards, and accountability for data quality.

Data taken from the primary record and reorganized for another purpose, such as a registry or index.

The health record itself, created during direct patient care.

A list of diseases and conditions, organized by ICD code, used to locate records for study or reporting.

A list of procedures performed, organized by code, used to retrieve cases for review or research.

A list of cases organized by attending or operating physician.

A secondary data system that tracks cancer cases, treatment, and outcomes for reporting and research.

A database of trauma cases used to evaluate and improve trauma care and outcomes.

A vital record documenting a birth; HIM staff often help ensure timely, accurate completion.

A data-quality characteristic meaning the data are correct, valid, and free of error.

A data-quality characteristic meaning all required data elements are present.

A data-quality characteristic meaning data mean the same thing across systems and time.

A data-quality characteristic meaning data are up to date and recorded near the time of the event.

A data-quality characteristic meaning data are captured at the right level of detail for their use.

A data-quality characteristic meaning the data collected are meaningful for their intended purpose.

A policy specifying how long each type of record must be kept before it can be destroyed.

The secure, irreversible disposal of records after the retention period, documented per policy.

A directive to preserve records relevant to anticipated or pending litigation, suspending normal destruction.

An accrediting body whose standards (e.g., for documentation timeliness) hospitals must meet.

CMS requirements a facility must meet to be reimbursed by Medicare and Medicaid.

A list of error-prone abbreviations (e.g., U for unit) that must not be used in documentation.

A change to an existing health-record entry that keeps the original entry visible and intact.

Documentation added after the time of service, labeled and dated as a late entry without altering prior notes.

Additional information appended to a record entry to clarify or complete prior documentation.

Tracking successive versions of a document or template so the correct, current one is in use.

Migrating documentation from a paper record into the electronic health record system.

A health record that exists partly on paper and partly in electronic systems.

The number of inpatients present in a facility at a given time, typically counted at midnight.

The unique number assigned to a patient's record, often via a unit numbering system.

A filing system in which a patient keeps one record number for all visits, consolidating documentation.

A system in which a patient receives a new record number at each admission.

A system that issues a new number each visit but brings prior records forward to the latest number.

A paper-filing method that orders records by the last digits of the record number to distribute filing evenly.

A tracking system that flags incomplete charts and routes them to providers for completion.

Rules — from coding guidelines, CMS, the Joint Commission, and law — that govern record content and quality.

A document listing each source system and whether its output is part of the legal health record.

The designated record set is broader (decision-making records); the legal health record is the version released for legal requests.

Health data created by the patient (e.g., home readings); generally not part of the legal health record.

A digital, longitudinal record of a patient's health information maintained by providers over time.

A health record maintained and controlled by the patient, separate from the provider's legal record.

Data stored in defined fields with controlled values, allowing easy search and analysis.

Free-text or narrative data (e.g., a dictated note) not stored in discrete fields.

Organizing records or data so specific cases can be located, such as by disease, operation, or physician.

An organized secondary data system that collects, stores, and reports cases of a defined type (e.g., cancer).

The standardized minimum data items, such as those defined by the UHDDS, collected for each encounter.

HIM's responsibility to maintain accurate, complete, secure, and properly governed health information.

Health Insurance Portability and Accountability Act — sets national standards to protect health information.

The HIPAA rule governing the use and disclosure of protected health information (PHI).

The HIPAA rule that protects electronic PHI through administrative, physical, and technical safeguards.

Individually identifiable health information held or transmitted by a covered entity in any form.

Electronic protected health information — PHI created, stored, or transmitted electronically.

Using or disclosing only the least amount of PHI needed to accomplish the intended purpose.

Disclosures for treatment are exempt from the minimum-necessary standard.

Treatment, payment, and health-care operations — uses and disclosures of PHI permitted without authorization.

A patient's signed permission to use or disclose PHI for a purpose not otherwise permitted by HIPAA.

A patient's right to a list of certain disclosures of their PHI, with date, recipient, description, and purpose.

A patient's right to inspect and obtain a copy of their PHI in the designated record set.

A document informing patients how their PHI may be used and disclosed and of their privacy rights.

A health plan, health-care clearinghouse, or provider that transmits health information electronically.

A person or entity that performs functions involving PHI on behalf of a covered entity.

A contract requiring a business associate to safeguard PHI as HIPAA requires.

The process of disclosing PHI to authorized requesters according to law and policy.

An authorization that is specific, dated, signed, and not expired, naming the information and recipient.

A person with legal authority to act for a patient (e.g., guardian, healthcare proxy) regarding PHI.

Specially protected notes that generally require separate, specific authorization to disclose.

Categories such as substance use, HIV, and mental health that have heightened disclosure restrictions.

Federal rules giving extra confidentiality protection to substance-use-disorder treatment records.

An impermissible use or disclosure of PHI that compromises its security or privacy.

The requirement to notify affected individuals (and others) after a breach of unsecured PHI.

A law that promoted EHR adoption and strengthened HIPAA enforcement and breach notification.

A review of who accessed PHI and whether the access was appropriate and authorized.

A review of safeguards and system activity to verify ePHI is protected against unauthorized access.

An automatic log of system activity recording who accessed what data, when, and what action they took.

Technical safeguards that limit system access to authorized users (e.g., unique IDs, role-based access).

Granting users only the access their job role requires — a minimum-necessary safeguard.

Converting data into a coded form so only authorized parties can read it, protecting ePHI.

Verifying a user's identity before granting access, typically via a unique password or credential.

A technical safeguard that controls network traffic to block unauthorized access to systems.

The obligation to keep PHI private and disclose it only to authorized parties.

Assurance that ePHI is not improperly altered or destroyed.

Assurance that ePHI is accessible and usable by authorized persons when needed.

A required assessment of risks and vulnerabilities to ePHI to guide safeguards.

A policy specifying penalties for workforce members who violate privacy or security rules.

Required education of staff on privacy and security policies and their responsibilities.

A record of accountable disclosures used to produce a patient's accounting of disclosures.

A legal order to produce records or testimony; HIM verifies validity before releasing PHI.

A judge's directive that may compel disclosure of PHI even without patient authorization.

A notice that information released may not be further disclosed without authorization.

The average DRG relative weight for a group of inpatients — sum of DRG weights ÷ number of discharges.

A higher CMI reflects a more resource-intensive, higher-acuity patient population.

(Number of inpatient deaths ÷ total discharges, including deaths) × 100, for a period.

Death rate excluding deaths occurring less than 48 hours after admission.

(Inpatient autopsies ÷ total inpatient deaths) × 100.

Autopsy rate excluding bodies not available for autopsy (e.g., released to the coroner).

Autopsies on hospital patients ÷ deaths of hospital patients whose bodies were available, × 100.

(Number of hospital-acquired infections ÷ total discharges) × 100, for a period.

(Infections in clean surgical cases ÷ number of surgical operations) × 100.

(Number of C-section deliveries ÷ total deliveries) × 100.

Total inpatient service days for a period ÷ number of days in the period.

Total length-of-stay days (discharge days) for discharges ÷ number of discharges.

The number of days from admission to discharge for a single patient (admission and discharge counted as one day).

A unit measuring the services received by one inpatient in one 24-hour period.

(Inpatient service days ÷ available bed days) × 100, measuring bed utilization.

The number of times a bed changes occupants in a period, indicating bed use efficiency.

Extracting and recording relevant data elements from the record into a database or registry.

Examining data to find patterns and produce information that supports decisions.

Statistics that summarize data, such as counts, percentages, means, and rates.

The arithmetic average — sum of values ÷ number of values.

The middle value when data are ordered; resistant to extreme values.

The most frequently occurring value in a data set.

The difference between the highest and lowest values in a data set.

A measure comparing the number of times an event occurred to the number of times it could have occurred.

A comparison of two quantities, such as the ratio of staff to patients.

A type of ratio in which the numerator is included in the denominator.

A proportion expressed per 100.

Categorical data with no inherent order, such as gender or blood type.

Categorical data with a meaningful order but unequal intervals, such as pain scales.

Numeric data measured on a scale with meaningful intervals, such as weight or temperature.

A chart that displays categorical data using rectangular bars.

A chart that displays the frequency distribution of continuous data using adjacent bars.

A circular chart showing parts of a whole as proportional slices.

A chart that displays trends over time using connected points.

Standardized performance measures used to assess and report quality of care.

Submitting abstracted data to a registry (e.g., cancer) for tracking and analysis.

A system that collects and maintains data on patients with a specific condition for study and reporting.

Comparing performance metrics against an internal or external standard to identify improvement.

A metric of work output, such as charts coded or records analyzed per hour.

The proportion of incomplete records that remain delinquent past the allowed time limit.

Presenting data graphically (charts, dashboards) to communicate findings clearly.

A visual display of key metrics used to monitor performance at a glance.

Summarized data combined from many records, with individual identities removed.

Examining data over time to detect direction, patterns, or changes.

Distributing staff, time, and budget based on workload and statistical analysis.

For most hospital rates, the denominator is the number of discharges in the period.

A table showing how often each value or category occurs in a data set.

A measure of how spread out values are around the mean.

A data value far from the others that can distort the mean and may need review.

Analysis of data as it is generated, supporting immediate operational decisions.

The financial process from patient scheduling through final payment for services.

Accounts for discharged patients whose claims have not been sent, often due to incomplete coding.

Recording the services and supplies provided so they can be billed.

A master list of all billable items, services, and their charges used to generate claims.

A request asking a provider to clarify ambiguous, incomplete, or conflicting documentation.

A non-leading query supported by clinical indicators that does not suggest a diagnosis to raise payment.

A non-compliant query that steers the provider toward a specific, usually higher-paying answer.

Evaluating the medical necessity, appropriateness, and level of care of services.

The principle that a service is reasonable and necessary; diagnosis codes must support the service.

A payer's refusal to pay a claim, in whole or part, often for coding or documentation reasons.

The process of analyzing, appealing, and preventing claim denials to recover revenue.

A formal request asking a payer to reconsider a denied claim, supported by documentation.

A review of assigned codes against documentation to verify accuracy and compliance.

The U.S. code set for reporting diagnoses in all health-care settings.

The 7-character code set used to report inpatient hospital procedures.

Current Procedural Terminology — codes for physician and outpatient procedures and services.

Codes for supplies, drugs, equipment, and services not covered by CPT.

Medicare Severity Diagnosis-Related Group — the inpatient classification paying a fixed amount per admission.

Ambulatory Payment Classification — the payment unit under the hospital outpatient prospective payment system.

Inpatient Prospective Payment System — Medicare's method of paying acute hospitals per MS-DRG.

Outpatient Prospective Payment System — Medicare's method of paying hospital outpatient services via APCs.

DRGs pay for inpatient admissions; APCs pay for hospital outpatient services.

The condition after study chiefly responsible for admission; sequenced first for inpatients.

In outpatient coding, the reason chiefly responsible for the services, sequenced first.

Listing codes in the correct order — principal/first-listed diagnosis first, then secondaries.

Major complication or comorbidity — a secondary condition that can shift a case to a higher-paying DRG.

Complication or comorbidity — a secondary condition that raises the DRG tier less than an MCC.

Present on Admission indicator (Y, N, U, W) reported with each inpatient diagnosis.

A two-character CPT/HCPCS addition giving detail such as bilateral, repeat, or distinct service.

National Correct Coding Initiative edits that block improper code pairs and unbundling.

Reporting components of a service separately to gain higher payment when one code should be used.

Assigning a more severe or expensive code than the documentation supports — fraud.

Software that helps coders find and assign correct codes.

Software that classifies coded cases into a payment group such as an MS-DRG or APC.

Software that suggests codes via natural-language processing; a coder validates every code.

Efforts to ensure the record accurately and completely reflects the patient's clinical status.

A claim with no errors that can be processed and paid without additional information.

A payer document explaining how a claim was paid, adjusted, or denied.

A statement to the patient explaining what the payer covered and what the patient owes.

The time from discharge to completed coding — a key HIM standard affecting DNFB.

Coordinating a patient's post-discharge care needs before they leave the facility.

The types and severity of cases a facility treats, reflected in coding and reimbursement.

Adherence to official coding guidelines and rules to ensure accurate, ethical coding.

A policy defining when and how coders query providers in a compliant, non-leading way.

Knowingly submitting false claims for payment, such as billing for services not provided.

Practices inconsistent with sound fiscal or medical practice that result in unnecessary cost.

A CMS contractor that reviews claims to identify and recover improper payments.

The proportion of audited codes found correct — a core coding-quality metric.

An edit that checks whether the diagnosis supports the billed service.

Confirming that all services provided were captured and billed.

An organized effort to prevent, detect, and correct violations of laws, regulations, and policies.

Identifying and ranking where an operation could fail to meet requirements so resources target the highest risks.

Systematic evaluation of services or processes against standards to find improvement opportunities.

An ongoing process to improve outcomes and processes, often using PDCA cycles.

Plan-Do-Check-Act — a structured method for testing and implementing improvements.

AHRQ measures that screen coded data for potentially preventable in-hospital complications.

A reasonably preventable condition acquired during the stay; if not POA, it can reduce payment.

A serious, largely preventable adverse event that should never occur (e.g., wrong-site surgery).

An unexpected occurrence involving death or serious harm that triggers immediate investigation.

A structured process to find the underlying cause of an adverse event and prevent recurrence.

Principles requiring accurate, honest coding that reflects documentation, never upcoding.

Professional principles guiding honest, accountable conduct in HIM practice.

A documented plan to fix identified compliance problems and prevent recurrence.

A self-review of processes and records to detect compliance issues before external review.

A review by an outside party, such as a payer or accreditor, of compliance and accuracy.

Tracking changes in laws and regulations to implement them timely and accurately.

CMS requirements a facility must meet to participate in Medicare and Medicaid.

Voluntary review by an external body (e.g., the Joint Commission) confirming standards are met.

A state requirement permitting a facility or individual to operate or practice.

Confirmation that a provider meets federal standards to bill Medicare and Medicaid.

The level of care a reasonably prudent provider would deliver under similar circumstances.

Performance benchmarks for HIM functions such as chart completion, coding accuracy, and ROI turnaround.

A benchmark for how quickly and completely records must be finished after discharge.

A benchmark for the percentage of codes that must be correct on audit.

A benchmark for how quickly release-of-information requests are completed.

Activities aimed at raising the quality and efficiency of processes and outcomes.

The individual responsible for overseeing an organization's compliance program.

Legal protection for employees who report fraud or noncompliance in good faith.

A federal law imposing liability for knowingly submitting false claims to the government.

The Office of Inspector General's annual list of compliance focus areas and audits.

Educating staff on rules and policies so they can perform work compliantly.

A document recording an unexpected event or near miss; it is not part of the legal health record.

A measurable element of performance used to monitor and improve care quality.

A deviation from expected process or outcome that is tracked for quality and risk.

Evaluation of a provider's care by professional peers to assess quality.

Activities that identify and reduce the chance of loss, injury, or liability.

Ongoing review of metrics and audits to keep operations within compliance.

A defined channel for reporting suspected violations, such as a hotline.

Structured efforts to monitor and improve the accuracy and completeness of data.

Refining documentation practices so records support coding, quality, and compliance.

Putting a new rule into operational practice through updated policies and training.

Selecting a representative subset of records to review for accuracy or compliance.

Common exposure points such as coding errors, privacy breaches, and billing mistakes.

A program (e.g., Hospital IQR) requiring submission of quality data, often tied to payment.

A quality measure of whether a recommended action was performed (e.g., aspirin on arrival).

A quality measure of the result of care, such as mortality or readmission rate.

A high-level statement of what an organization will do and why — its rule on an issue.

The step-by-step actions staff follow to carry out a policy.

A policy states what and why; a procedure states how, step by step.

Training clinicians and staff on documentation, content, privacy, and HIM laws and regulations.

The ability of different systems to exchange and meaningfully use health data.

CMS programs (formerly Meaningful Use) encouraging EHR adoption and data exchange.

The earlier federal program promoting effective EHR use to improve care.

The electronic sharing of health information among organizations within a region or system.

Agreed formats and code sets (e.g., HL7, ICD-10) that let systems exchange data.

A standard for exchanging clinical and administrative health data between systems.

Examining an existing HIM process to find inefficiencies and improvement opportunities.

The sequence of steps and handoffs by which work moves through an HIM operation.

Restructuring steps and handoffs to improve efficiency and quality.

A documented routine for performing a recurring task consistently.

Guiding people and processes through a transition, such as an EHR upgrade.

Specialized HIM knowledge applied to support systems, data, and compliance.

Working with other departments (IT, billing, clinical) to support shared goals like interoperability.

Established benchmarks for chart completion, coding accuracy, ROI, and workflow.

Guiding and developing less-experienced staff to build skills and competence.

An expected output level for a role, used to plan staffing and measure performance.

A plan matching staff numbers and skills to the department's workload.

A document defining a position's duties, responsibilities, and required qualifications.

An organized set of activities to build staff knowledge and skills.

Communicating how an employee's work compares to standards to support improvement.

Planning, organizing, and overseeing tasks to complete a defined goal on time.

Working with software or service vendors to support HIM systems and goals.

Ongoing learning required to maintain a credential and current knowledge.

A person with deep expertise in a domain who advises on decisions and problems.