alphabetic index - a content list for a reference work organized by the first

letter of each entry

cancer - a disease in which cells multiply and grow in an unregulated fashion,
invading nearby structures and sometimes spreading to other parts of the body
Diagnostic and Statistical Manual of Mental Disorders-5th Edition (DSM5) - the current version of the DSM, a publication of the American Psychiatric
Association (APA) used as the primary resource in the US to classify and diagnose
mental disorders
explanation of benefits - a form created by the insurance company to explain
what charges were covered, denied, or need more documentation based on the
claims submitted by the physician's office
Health Care Procedure Coding System (HCPCS) a diagnosis and procedure
code nomenclature used for outpatient billing in the US
insurance reimbursement the process of receiving payment from an insurance
company for a covered benefit
International Classification of Diseases (ICD) a medical vocabulary system
sponsored by the United Nations World Health Organization (WHO) and used
worldwide to standardize death reporting statistics and communication
International Classification of Diseases for Oncology-3rd Revision (ICDO-3) an extension of the ICD for use in classifying neoplasms
International Classification of Diseases-10th Revision-Procedure
Classification System (ICD-10-PCS) a separate procedure code system in the
ICD-10 clinical vocabulary system
medical biller a professional who prepares and submits insurance claims for a
provider based on a medical coder's work
medical claims examiner a health insurance professional who examines
submitted medical claims to ensure that they are valid and qualify for payment
medical coder a specialist in medical coding
medical coding the process of assigning nomenclature codes to patient data
obtained by examining medical records
medical transcriptionist a specialist who creates a text-based medical record
from a voice recording
mental disorder a condition in which a person's thoughts, feelings, and/or
behaviors cause distress or impair the ability to function
neoplasm an abnormal growth of cells that may or may not form a tumor (solid
mass), and may or may not be malignant (cancerous)

nomenclature an organized system of words for use in a particular field

nursing vocabulary a nomenclature system used to communicate nursing
strategies, protocols, and procedures
oncology the medical specialty that focuses on cancer
procedure code a code assigned to a particular medical service or procedure
substance abuse a pattern of use of medications or substances that are not
part of an approved medical plan or treatment
Systematized Nomenclature of Medicine Clinical Terminology (SNOMED
CT) a multinational, multilingual, comprehensive medical nomenclature covering
all aspects of medicine
tumor a solid mass, which may or may not be cancerous
American Health Information Management Association (AHIMA) a not-forprofit professional organization serving the educational, credentialing,
networking, and advocacy needs of health information management (HIM)
professionals
Certification Commission for Health Information Technology (CCHIT) a
nonprofit organization with the mission of accelerating the adoption of
information technology (IT) in healthcare that measures and certifies the
effectiveness of EHR products based on predefined criteria
clinical data repository (CDR) a special database that manages healthcare
data from different sources such as labs, pharmacies, and radiology networks
compliance the process of adhering to state and federal laws
data quality characteristics the ten AHIMA data quality characteristics that
require data to be accurate, accessible, comprehensive, consistent, current,
defined, granular, precise, relevant, and timely
data quality management model an AHIMA concept that standardizes data
storage, maintenance, and organization according to ten quality characteristics
electronic data interchange (EDI) the digital exchange of structured data
between computer systems; reduces errors and can be used, for example, for
sending prescriptions to a pharmacy.
electronic health records (EHRs) health records that allow real-time
communication, reporting, and record keeping through electronic transmission
electronic medication administration record (EMAR) an EHR system for
medication management that uses the CDR database

electronic prescribing the digital authoring, transmission, and filling of

physician medication prescriptions, it is intended to reduce errors, time, and
costs.
examination also known as an exam, includes both a physician's physical
examination of a patient, as well as any test results
health information exchange (HIE) the digital exchange of healthcare data
between different organizations in order to improve patient care, and reduce
costs and errors
Health Information Management and Systems (HIMSS) a non-profit group
seeking to help healthcare providers implement information technology and
management strategies
Health Insurance Portability and Accountability Act (HIPAA) legislation
that provides guidelines on maintaining patient privacy and confidentiality
through standardized methods of handling healthcare data
history refers to a patient's past medical history, as well as the history of the
present illness
hospital information system (HIS) a computerized management solution that
handles all aspects of a hospital's operations, including financial and medical
operations
hybrid health records medical records that incorporate elements of paperbased records and electronic records
Institute of Medicine (IOM) a non-profit organization that makes policy
recommendations about the healthcare field
interoperability the ability to share data between multiple systems without
altering the meaning of the data
intranet a closed network of computers within a facility or organization
medical decision making component of the health record that substantiates the
care provided, supports reimbursement for each procedure, and serves as a legal
document that validates the treatment provided for each diagnosis
medical encounter a single patient-provider visit, during which the patient's
chief complaint (CC) and the history of the present illness (HPI) are discussed, a
physical examination (PE) is performed, and a diagnosis (DX) and treatment (TX)
plan are made
medical history a patient's health history, including information such as
allergies, medications being taken, past medical history (PMH, e.g., prior illnesses
and surgeries), social history (SH, e.g., occupation and habits such as smoking,
exercise, and alcohol use), and family history (FH)

medical record the lifetime record of a patient's health, health problems, and
medical care at a particular institution
National Health Information Network (NHIN) a set of standards, services,
and policies intended to enable interoperable health information exchange across
the nation
notice of privacy practices (NPP) a legally required notice that healthcare
providers and plans must distribute to their patients that outlines how their
protected health information is used and disclosed, and the rights the patient has
patient care charting system a type of EHR that records progress notes and
assessments
patient confidentiality protection from private healthcare information being
released without prior permission
pay for performance (P4P) performance-oriented incentives for hospitals and
physicians to improve the quality of patient healthcare
personal health record (PHR) a medical record that is maintained by the
patient for personal benefit
privacy rule a part of HIPAA that outlines standards for maintaining patient
confidentiality and safeguarding financial and administrative data during
electronic transfer
protected health information (PHI) any information about a person's health,
healthcare, or payment for health services that can be linked to a specific patient
alphanumeric filing system a method of organizing health records by
combining the first two letters of the patient's surname with a numerical
identifier
birth certificate completion the process of fully completing an infant's birth
certificate
breach of confidentiality disclosure of patient information without prior written
consent
deficiency slip a report generated to notify staff that a medical record is missing
required information
disease and operation index a database of diagnoses made and procedures
performed in a healthcare organization
health data security the process of ensuring that medical records are
unaltered, readily accessible, and used legitimately
health informatics a branch of health information management that uses
computer systems to gather, organize, maintain, and store patient healthcare
data

requisition a written request for a health record

traditional health record a medical chart stored and maintained in paper
format
World Health Organization (WHO) a global organization, created by the
United Nations, that provides global leadership on health, health research, and
health policy