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HIM chapter 01
| Term | Definition |
|---|---|
| adaptive skills | behavior and daily living skills that demonstrate the job seeker’s ability to fit into the organization’s culture |
| AHIMA Foundation | the charitable affiliate of the American Health Information Management Association that provides funding and resources for research, education, and career development |
| ACS | American College of Surgeons |
| American Health Information Management Association (AHIMA) | the professional membership organization for individuals interested in or involved in the field of health information management |
| body language | nonverbal communication that sends a visual message to another person |
| cancer registrar/tumor registrar | a specialist who reviews patient records for diagnoses and treatments related to cancer and then abstracts the cancer-related data into a database |
| clinical documentation improvement (CDI) specialist | a specialist who works with physicians in an acute care setting to ensure that the documentation in the medical record supports all of the diagnoses and procedures provided to a patient |
| CAHIIM | Commission on Accreditation for Health Informatics and Information Management Education |
| CE | continuing education |
| critical thinking | the intellectually disciplined process of thinking that is clear, rational, open-minded, and supported by evidence |
| EHR implementation coordinator and trainer | an individual who assists in the selection and implementation of the electronic health record system, develops training materials, and trains users |
| ethics | standards of behavior based on moral values |
| file/scanning and retrieval clerk | an entry-level clerical position that involves preparing documents for final storage and may include pulling paper records from storage or responding to customer requests for access to electronic records |
| health information management (HIM) | the practice of maintaining, analyzing, and protecting confidential patient information contained in the health record |
| health record | a medical record into which the healthcare provider records the patient’s medical information every time the provider assesses or treats the patient |
| HIM technician | a general clerical staff position in the HIM department; responsibilities may include record assembly and analysis, transcription processing and routing, physician completion activities, and release of information |
| hospital medical coder | a coding specialist who reviews documentation in the medical record and assigns each reportable diagnosis and procedure an alphanumeric code |
| job skills | skills gained through paid or volunteer work—including those skills developed and sharpened at home or in school |
| medical biller and coder | a clerical staff position in a physician office or physician billing company that involves entering pre-coded information from a physician’s charge ticket |
| medical scribe | an unlicensed person who enters patient information into an electronic health record or the paper chart at the direction of a physician |
| medical transcriptionist | a healthcare documentation specialist or medical editor who transcribes physician dictation |
| performance improvement coordinator | an individual who coordinates technical and analytical support for quality and performance improvement (PI) initiatives and medical peer- review activities |
| physician office manager | the position responsible for the overall operations of the medical office, including hiring, assessing and training staff, negotiating insurance contracts, preparing and monitoring budgets, paying invoices, and monitoring billing and accounts receivable |
| privacy officer | person whose job is to establish policies to protect the confidentiality of protected health information (PHI), educate personnel on HIPAA Privacy Rule, audit PHI access, handle complaints, and produce reports for internal and governmental use |
| professionalism | the conduct, aims (aspirations and intentions), and qualities that characterize or mark a professional person |
| résumé | a marketing tool that a job seeker uses to promote his or her skills and value to an organization |
| supervisor/manager | the position responsible for human resource activities such as hiring, counseling, firing, and training staff |
| transferable skills | skills that can be transferred from one occupation to another |
| vital statistics clerk | a clerical position that involves preparing birth and death certificates and submitting the information to the appropriate state agency |
| American College of Surgeons (ACS) | an association founded in 1913 to improve the quality of care for surgical patients through improved education and training |
| AHIMA | American Health Information Management Association |
| Commission on Accreditation for Health Informatics and Information Management Education (CAHIM) | an independent accrediting organization that promotes and enforces accreditation standards for health information and health informatics education programs |
| continuing education (CE) | educational requirements that a health information management professional must meet to maintain professional certification |
| HIM | health information management |
| CDI | clinical documentation improvement |
Created by:
softcrylic