Chapter 2: The Health Information Management Department

Abstracting
collection of data from the medical record for statistical and planning purpose.
Analysis
Reviewing the medical record to determine that all required documentation is present including signatures and reports.
Cancer registry
A database of patients diagnosed with cancer.
Coding
Assignment of numbers to diagnoses and/or procedures and using the current edition of a coding or classification system such as the International Classification of Diseases (ICD) or current Procedural Terminology (CPT).
Deficiency Slip
A document that identifies deficiencies in documentation
Healthcare provider
an Individual or facility, such as a hospital, that provides healthcare to a patent.
JCAHO
Joint Commission on the Accreditation of Healthcare Organizations
Litigation
Law Suit
Medical Record Number
A unique number assigned to a medical record in order to identify it.
Medical transcription
interpretation and typing of reports dictated by physicians and other healthcare personnel
Medicare
Federal insurance for patients over 65 or for the disabled
Performance improvement
evaluating the performance of a healthcare facility, from the environment to the patient care, with the purpose of continuous improvement.
Periodical
A magazine or journal published at specified periods, for example, weekly or monthly
Physician Incomplete Area
Area of the health information management department where physicians come to work on incomplete records.
Physician Progress Note
Handwritten or typed entries made by the physician regarding the patient’s progress during hospitalization or other treatment
Risk management
Addressing the risk to which patients, visitors, hospital staff, medical staff, vendors and others are exposed
Third party
A person or entity, such as an insurance company, other than the healthcare facility or patient.