Medical Terminology – Health Information Technology Word List

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health information management (HIM)
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the management of patient healthcare data of all types
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information technology
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the process needed to assimilate, organize, maintain, and store patient healthcare data
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health informatics
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a branch of health information management that uses computer systems to gather, organize, maintain, and store patient healthcare data
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traditional health record
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a medical chart stored and maintained in paper format
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electronic medical record (EMR)
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digitally stored and accessed patient records that allow real-time communication, reporting, and recordkeeping through electronic transmission; also called electronic health records (EHRs) or computer-based patient records (CPRs)
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hybrid health record
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a medical record that incorporates elements of paper-based records and electronic records
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alphabetical filing system
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a method of organizing health records according to the patients surname
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numerical filing system
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a method of organizing health records according to a unique patient identification number
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alphanumeric filing system
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a method of organizing health records by combining the first two letters of the patient’s surname with a numerical identifier
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out guide
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a card placed in a collection of paper files to indicate that a file has been removed
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requisition
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a written request for a health record
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quality management
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the process of planning, controlling, and improving the quality of a product or system
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deficiency slip
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a report generated to notify staff that a medical record is missing required information
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index
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a database that contains pertinent healthcare information that can be used for research, healthcare quality control, or statistical purposes
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master patient index
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the primary index used for HIM record keeping, which includes a unique record for each patient within a healthcare organization
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physician index
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a database that records the physician associated with each patient, diagnosis made, and procedure performed at a healthcare organization
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registry
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a database of information concerning births, deaths, admissions, and discharges
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Centers for Disease Control and Prevention (CDC)
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a United States government organization that seeks to promote healthy behaviors and the prevention of disease, injury, and disability
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World Health Organization (WHO)
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a global organization, created by the United Nations, that provides global leadership on health, health research, and health policy
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cancer and trauma registries
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compilations of healthcare data on different types of cancers and traumatic events
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birth certificate completion
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the process of fully completing an infant’s birth certificate
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statistical and research services
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data analysis services provided for health information professionals who are conducting medical studies of tracking diseases
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medical transcription
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the process of creating a text-based medical record from a voice recording
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health data security
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the process of ensuring that medical records are unaltered, readily accessible, and used legitimately
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Health Insurance Portability and Accountability Act (HIPAA)
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a law governing the portability of health insurance when workers change jobs, the standards for electronic healthcare transactions, and the security and privacy of health data
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privacy rule
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a part of HIPAA that outlines standards for maintaining patient confidentiality
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breach of confidentiality
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disclosure of patient information without prior written consent
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protected health information (PHI)
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any information about a person’s health, healthcare, or payment for health services that can be linked to a specific patient
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Department of Health and Human Services (HHS)
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a United States government organization that establishes guidelines for health information management compliance
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Office of the Inspector General (OIG)
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investigates abuse, fraud, waste, and mismanagement within a government organization
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American Health Information Management Association (AHIMA)
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a not-for-profit professional organization serving the education, credentialing, networking, and advocacy needs of health information management (HIM) professionals

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