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Chapter 2

The Health Information Management Department

Abstracting Collection of data from the medical record for statistical and planning purposes.
Analysis Reviewing the medical record to determine that all required documentation is present including signatures and reports.
Cancer registry A database of patients diagnose with cancer.
Coding Assignment of numbers to diagnoses and/or procedures 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 patient.
JCAHO Joint Commission on the Accreditation of Healthcare Organizations.
Ligitation Lawsuit.
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 overall 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 physician regarding the patient's progress during hospitalization or other treatment.
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.
Created by: yunue03