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Key terms from book titled Health Information Management Technology An Applied Approach, by Merida L. Johns, PhD, RHIA 3rd edition

health record

A paper- or computer-based tool for collecting and storing information about the healthcare servcies provided to a patient in a single healthcare facility; also called a patient record, medical record, resident record, or client record, depending on the healthcare setting


The dates, numbers, images, symbols, letters, and words that represent basic facts and observations about people, processes, measurements, and conditions


Factual data that have been collected, combined, analyzed, interpreted, and/or converted into a form that can be used for a specific purpose

electronic health record

(EHR) An electronic record of health-related information on an individual that conforms to nationally recognized interoperability standards and that can be created, managed, and consulted by authorized clinicians and staff across more than one healthcare organization

personal health record

(PHR) An electronic record of health-related information on an individual that conforms to nationally recognized interoperability standards and that can be drawn from multiple sources while being managed and controlled by the individual


A specially trained typist who understands medical terminology and translates physicians' verbal dictation into written reports

allied health professional

A credentialed healthcare worker who is not a physician, nurse, psychologist, or pharmacist (for example, a physical therapist, dietitian, social worker, or occupational therapist)

accreditation organization

A professional organization that establishes the standards against which healthcare organizations are measured and conducts periodic assessments of the performance of individual healthcare organizations

third-party payer

An insurance company (for example, Blue Cross/Blue Shield) or healthcare program (for example, Medicare) that reimburses healthcare providers (second party) and/or patients (first party) for the delivery of medical services

coding specialist

The healthcare worker responsible for assigning numeric or alphanumeric codes to diagnostic or procedural statements

aggregate data

Data extracted from individual health records and combined to form deidentified information about groups of patients that can be compared and analyzed


Compensation or repayment for healthcare services

diagnostic codes

Numeric or alphanumeric characters used to classify and report diseases, conditions, and injuries

procedural codes

The numeric or alphanumeric characters used to classify and report the medical procedures and services performed for patients

quality improvement organizations

(QIO) An organization that performs medical peer review of Medicare and Medicaid claims, including review of validity of hospital diagnosis and procedure coding information; completeness, adequacy, and quality of care; and appropriateness of prospective payments for outlier cases and nonemergent use of the emergency room; until 2002, called peer review organization

utilization management organization

An organization that reviews the appropriateness of the care setting and resources used to treat a patient

Centers for Medicare and Medicaid Services

(CMS) The division of the Department of Health and Human Services that is responsible for developing healthcare policy in the United States and for administering the Medicare program and the federal portion of the Medicaid program; called the Health Care Financing Administration (HCFA) prior to 2001

data quality management

A managerial process that ensures the integrity (accuracy and completeness) of an organization's data during data collection, application, warehouseing, and analysis

data accuracy

The extent to which data are free of identifiable errors

data accessibility

The extent to which healthcare data are obtainable

data comprehensiveness

The extent to which healthcare data are complete

data consistency

The extent to which healthcare data are reliable

data currency

The extento to which data are up-to-date; See data timeliness

data timeliness

Concept of data quality that involves whether the data is up-to-date and available within a useful time frame; See data currency

data definition

The specific meaning of a healthcare-related data element

data granularity

The level of detail at which the attributes and values of healthcare data are described

data precision

The extent to which data have the values they are expected to have

data relevancy

Th extent to which healthcare-related data are useful for the purpose for which they were collected


The quality or state of being hidden from, or undisturbed by, the observation or activities of other persons or freedom from unauthorized intrusion; in healthcare-related contexts, the right of a patient to control disclosure of personal information


A legal and ethical concept that establishes the healthcare provider's responsiblity for protecting health records and other personal and private information from unauthorized use or disclosure


The means to control access and protect information from accidental or intentional disclosure to unauthorized persons and from unauthorized alteration, destruction, or loss.

source-oriented health record format

A system of health record organization in which information is arranged according to the patient care department that provided the care

problem-oriented health record format

A health record documentation approach in which the physician defines each clinical problem individually

integrated health record format

A system of health record organization in which all the paper forms are arranged in strict chronological order and mixed with forms created by different departments

hybrid health record

The health record that includes both paper and electronic elements

results management

Results retrieval technology that permits viewing of data by type and manipulation of several different types of data; also referred to as results managment systems

clinical decision support

(CDS) The process in which individual data elements are represented in the computer by a spcecial code to be used in making comparisons, trending results, and supplying clinical reminders and alerts

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