Quality improvement (QI): A set of activities that measures the quality of a service or product through systems or process evaluation and then implements revised processes that result in better healthcare outcomes for patients, based on standards of care
Quality improvement organization (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
Records disaster recovery policy: A policy that establishes how records should be handled in a disaster such as a fire
Reference terminology: A set of concepts and relationships that provide a common consultation point for the comparison and aggregation of data about the entire healthcare process, recorded by multiple individuals, systems, or institutions
Referral: A request by a provider for a patient under the provider’s care to be evaluated and/or treated by another provider
Registered Health Information Administrator (RHIA): Registered Health Information Administrator. A type of certification granted after completion of an accredited program in health information management and a credentialing examination. RHIA's are skilled in the collection, interpretation, and analysis of patient data. Additionally, they receive the training necessary to assume managerial positions related to these functions
Registered Health Information Technician (RHIT):Registered Health Information Administrator. A type of certification granted after completion of an accredited two-year program in health information management and a credentialing examination. RHIT's are health information technicians who ensure the quality of medical records by verifying their completeness, accuracy, and proper entry into computer systems. RHITs often specialize in coding diagnoses and procedures in patient records for reimbursement and research.
Registered nurse (RN): A graduate nurse who has passed examinations for registration
Regulation: A rule or order having the force of law issued by executive authority of the government
Registry: A collection of care information related to a specific disease, condition, or procedure that makes health record information available for analysis and comparison
Rehabilitation: The process of restoring a disabled insured to maximum physical, mental, and vocational independence and productivity (commensurate with their limitations) through the identification and development of residual capabilities, job modifications, or retraining
Release of information (ROI): The process of disclosing patient-identifiable information from the health record to another party
Request for information (RFI): A written communication often sent to a comprehensive list of vendors during the design phase of the systems development life cycle to ask for general product information
Respiratory therapy (RT): The practice involved in enhancing respiratory function for the resident
Revenue cycle: The process of how patient financial and health information moves into, through, and out of the healthcare facility, culminating with the facility receiving reimbursement for services provided
Risk management (RM): A comprehensive program of activities intended to minimize the potential for injuries to occur in a facility and to anticipate and respond to ensuing liabilities for those injuries that do occur
Security: 1. The means to control access and protect information from accidental or intentional disclosure to unauthorized persons and from unauthorized alteration, destruction, or loss 2. The physical protection of facilities and equipment from theft, damage, or unauthorized access; collectively, the policies, procedures, and safeguards designed to protect the confidentiality of information, maintain the integrity and availability of information systems, and control access to the content of these systems
Security standards: Statements that describe the processes and procedures meant to ensure that patient-identifiable health information remains confidential and protected from unauthorized disclosure, alteration, and destruction
Sentinel event: According to the JCAHO, an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof
Skilled nursing facility (SNF): A long-term care facility with an organized professional staff and permanent facilities (including inpatient beds) that provides continuous nursing and other health-related, psychosocial, and personal services to patients who are not in an acute phase of illness but who primarily require continued care on an inpatient basis
Standard: 1. A scientifically based statement of expected behavior against which structures, processes, and outcomes can be measured 2. A model or example established by authority, custom, or general consent or a rule established by an authority as a measure of quantity, weight, extent, value, or quality
Standard of care: An established set of clinical decisions and actions taken by clinicians and other representatives of healthcare organizations in accordance with state and federal laws, regulations, and guidelines; codes of ethics published by professional associations or societies; regulations for accreditation published by accreditation agencies; usual and common practice of equivalent clinicians or organizations in a geographical regions
Systematized Nomenclature of Human and Veterinary Medicine (SNOMED): A comprehensive clinical vocabulary developed by the College of American Pathologists that is the most promising set of clinical terms available for a controlled vocabulary for healthcare
Systemized Nomenclature of Medicine Clinical Terminology (SNOMED CT): A comprehensive, controlled clinical vocabulary developed by the College of American Pathologists
Systems analyst: An individual who investigates, analyzes, designs, develops, installs, evaluates, and maintains an organization’s healthcare information systems; is typically involved in all aspects of the systems development life cycle; and serves as a liaison among end users and programmers, database administrators, and other technical personnel
Taxonomy: The principles of a classification system, such as data classification, and the study of the general principles of scientific classification
Telemedicine: A telecommunications system that links healthcare organizations and patients from diverse geographic locations and transmits text and images for (medical) consultation and treatment
Terminology: A set of terms representing the system of concepts of a particular subject field; a clinical terminology provides the proper use of clinical words as names or symbols
Transcription: The process of deciphering and typing medical dictation
Transcriptionist: A specially trained typist who understands medical terminology and translates physicians’ verbal dictation into written reports
Trauma center: An emergency care center that is specially staffed and equipped (usually with an air transport system) to handle trauma patients
Triage: 1. The sorting of, and allocation of treatment to, patients 2. An early assessment that determines the urgency and priority for care and the appropriate source of care
Academic Pathways
Overview of AHIMA