Electronic health record (EHR): A computerized record of health information and associated processes
Encryption: The process of transforming text into an unintelligible string of characters that can be transmitted via communications media with a high degree of security and then decrypted when it reaches a secure destination
Encoder: Specialty software used to help the coder assign diagnosis and procedure codes
Ethical decision making: The process of requiring everyone to consider the perspectives of others, even when they do not agree with them
Executive information system (EIS): An information system designed to combine financial and clinical information for use in the management of business affairs of a healthcare organization; See executive decision support system
Face sheet: Usually the first page of the health record that contains resident identification, demographics, original date of admission, insurance coverage or payment source, referral information, hospital stay dates, physician information, and discharge information, as well as the name of the responsible party, emergency and additional contacts, and the resident’s diagnoses
Fee schedule: A list of healthcare services and procedures (usually CPT/HCPCS codes) and the charges associated with them developed by a third-party payer to represent the approved payment levels for a given insurance plan; also called table of allowances
Grouper: A computer software program that automatically assigns prospective payment groups on the basis of clinical codes
HCPCS Healthcare Common Procedural Coding System (HCPCS): A classification system that identifies healthcare procedures, equipment, and supplies for claim submission purposes; the three levels are as follows: I, Current Procedural Terminology codes, developed by the AMA; II, codes for equipment, supplies, and services not covered by Current Procedural Terminology codes as well as modifiers that can be used with all levels of codes, developed by CMS; and III (eliminated December 31, 2003 to comply with HIPAA), local codes developed by regional Medicare Part B carriers and used to report physicians’ services and supplies to Medicare for reimbursement
Healthcare informatics: The field of study that focuses on health information, its structure, acquisition, and use
Healthcare Information and Management Systems Society (HIMSS): A national membership association that provides leadership in healthcare for the management of technology, information, and change
Healthcare operations: Certain activities undertaken by or on behalf of, a covered entity, including those involved with quality assessment, performance improvement, peer review, clinical training, underwriting, legal services, compliance, and business management functions
Healthcare practitioner: A clinical professional who is directly responsible for providing patient services
Healthcare provider: A provider of diagnostic, medical, and surgical care as well as the services or supplies related to the health of an individual and any other person or organization that issues reimbursement claims or is paid for healthcare in the normal course of business
Health information management (HIM): An allied health profession that is responsible for ensuring the availability, accuracy, and protection of the clinical information that is needed to deliver healthcare services and to make appropriate healthcare-related decisions
Health information management (HIM) professional: An individual who has received professional training at the associate or baccalaureate degree level in the management of health data and information flow throughout healthcare delivery systems; formerly known as medical record technician or medical record administrator
Health information services department: The department in a healthcare organization that is responsible for maintaining patient care records in accordance with external and internal rules and regulations;
Health Information Specialist: Professionals who use health information technology and Electronic Health Records(EHRs) to perform their work
Health Insurance Portability and Accountability Act of 1996 (HIPAA): The federal legislation directed at improving access, affordability and continuity of health coverage, controlling fraud and abuse in healthcare, reducing costs, and ensuring the security and privacy of health information The act limits exclusion for preexisting medical conditions, prohibits insurance companies from denying coverage to individuals or businesses on the basis of health status, and guarantees availability of health insurance to small employers
Health maintenance organization (HMO): Entity that combines the provision of healthcare insurance and the delivery of healthcare services, characterized by: (1) organized healthcare delivery system to a geographic area, (2) set of basic and supplemental health maintenance and treatment services, (3) voluntarily enrolled members, and (4) predetermined fixed, periodic prepayments for members’ coverage
Health record: A paper- or computer-based tool for collecting and storing information about the healthcare services 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
Health record ownership: The generally accepted principle that individual health records are maintained and owned by the healthcare organization that creates them but that patients have certain rights of control over the release of patient-identifiable (confidential) information
Home health (HH): An umbrella term that refers to the medical and nonmedical services provided to patients and their families in their places of residence
Hospice: An interdisciplinary program of palliative care and supportive services that addresses the physical, spiritual, social, and economic needs of terminally ill patients and their families
Hospice care: The medical care provided to persons with life expectancies of six months or less who elect to forgo standard treatment of their illness and to receive only palliative care
Hospital: A healthcare entity that has an organized medical staff and permanent facilities that include inpatient beds and continuous medical/nursing services and that provides diagnostic and therapeutic services for patients as well as overnight accommodations and nutritional services
Hospital information system (HIS): The comprehensive database containing all the clinical, administrative, financial, and demographic information about each patient served by a hospital
Hospital inpatient: A patient who is provided with room, board, and continuous general nursing services in an area of an acute care facility where patients generally stay at least overnight
Academic Pathways
Overview of AHIMA