Health Informantics & Information Hlth Mngmt Career
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| accredited record technician | credential offered early 1950' after completion 9-12month tech program & successful completion certification exam
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| replaced by RHIT Registered Health Information Technician | accredited record technician
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| certification | process by which gov & nongov organizations evaluate ed programs, health care facilities, & individuals having met predetermined standards
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| certified coding associate (CCA) | entry-level coding credential implemented by AHIMA in 2002
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| recomended experience for credential is 6months or completion of AHIMA-approved coding certificate program/other formal training | certified coding associate (CCA)
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| certified coding specialist (CCS) | advanced coding crendential implemented by AHIMA in 1992
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| must pass CCS exam, focusing on inpatient coding systems; recommended exp. 3+ years | certified coding specialist (CCS)
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| certified coding specialist-physician based (CCS-P) | adv coding credential implemented by AHIMA in 1997
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| must pass CCS-P exam, focusing on ambulatory care coding; recommended exp. 3+ yrs | certified coding specialist-physician based (CCS-P)
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| code of ethics | guides practice of people who choose given profession & sets forth values & principles defined by profession as acceptable behavior within practice setting
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| Commission on Accreditation of Health Informatics and Information Management CAHIIM | accrediting body est. by AHIMA 2004 for undergraduate HIM programs prev. accredited by CAAHEP Council on Accreditation of Allied Health Educational Programs
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| CAHIIM also offers accreditation program for | master's degree programs in HIM which will convert to accreditation process in future
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| Communities of Practice (CoP) | on-line communication tool offered by AHIMA for connecting association members
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| provides up-to-date news & links to resources, helps keep mbrs informed on latest HIM trends, solve problems, network & career build | Communities of Practice (CoP)
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| credential | denotes that individuals have met specific standards & demostrated level of competence in field of practice
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| required to maintain over time by meetins CE requirements as defined by agency/association supporting such | credentials
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| electronic health information management | use of emerging info & communications tech to manage health info systems
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| hybrid record | record including both paper & electronic documents & uses both manual & electronic processes to store/review docs
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| information | data organized & processed into meaningful form, either manually/by computer to make valuable to user
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| adds to representation & tells recipient something not known before | information
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| knowledge | derived from information once information is organized, analyzed, & synthesized by user
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| licensure | legal approval for facility to operate/person to practice within his/her profession
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| individual must meet eligibility requirements defined by state before granted to practice | licensure
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| licensure occurs at ___ level & is overseen by ___ | state; state licensing board/agency
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| National health information infrastructure |
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| Office of the National Coordinator for Health Information Technology | role within HHS charged with providing national leadership in support of gov & priv efforts to develop standards & infrastructure to more effectively use info tech to acheive quality hlth care & reduce hlth care costs
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| position created by Pres. Bush 2004 & reports to Secretary of HHS | Office of the National Coordinator for Health Information Technology
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| profession | occupation requiring extensive training & study/mastery of specialized knowledge & skill
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| usually has a professional association, ethical code, & process of certification/licensing | profession
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| Regional health information organizations (RHIOs) | organizations working together develop means of sharing hlth info for patient care & other uses, typically within geographical area
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| various models exist incl models where info stays with originators & accessed as auth, & models centralize data & control of access as auth | Regional health information organizations (RHIOs)
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| RHIOs are part of the development of | a national hlth info infrastructure
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| Registered health information administrator (RHIA) | offered by AHIMA for those passing cert. exam & meet ed. req. CAHIIM-accredited HIM program-baccalaureate dgree lvl, or cert. of completion CAHIIM-accr. HIM program plus baccalaureate degree from regionally accredited college/univ.
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| credential offered by AHIMA, that functions in managerial lvls of health services & info sys & uses of health-related data for planning, delivering, & evaluating healthcare | Registered health information administrator (RHIA)
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| Registered health information technician (RHIT) | AHIMA credential for those who pass cert. exam & meet academic req. of CAHIIM-accredited HIM prog. at assoc. degree lvl
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| functions in technical areas of hlth data collection, analysis, & monitoring, often specializing in coding diagnoses/procedures for reimb. & research purposes | Registered health information technician (RHIT)
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| data | facts, ideas, concepts that can be captured, communicated & processes manually/electronically
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| record | body of known/recorded facts regarding someone/thing.
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| when patient seeks care/treatment from HCP a ___ of care/treatment is generated | record
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| primary professional association for HIM professionals, in US | American Health Information Management Association (AHIMA)
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| as a result of advances in information & communication technology HIM profession is | undergoing fundamental changes in way hlth care data/info collected, processed, communicated & managed
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| for the inception, HIM profession's focus has been | improving patient care through better documentation & ensuring privacy, confidentiality & securtiy of patient info
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| primary source of health data & info for the health care industry | patient record
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| a record can also be referred to with the following words in front of it | patient, medical, health, clinical, resident, client, etc.
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| patient records is created as a direct result of | health care delivered in that setting
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| data, information, or record may have "clinical" preceeding it to denote that | it relates specifically to care & treatment of a patient
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| heightened reliance by providers on patient record for source of data or decision making when | health care providers are working collaboratively to provide most effective treatment/care for patient
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| basis for health care billing reimbursement | documentation within patient record
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| use data in record as proof of care delivered to patient | third-party payers
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| health care setting/provider will not be reimbursed for services rendered without | proper documentation
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| efforts to control spiraling health care costs has placed extra importance | on the patient record
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| patient record also functions as a legal document that | confirms whether treatment was delivered in manner appropriate for given hlth problem
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| record can serve as proof in a court of law as to | what transpired during patient's course of treatment
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| as a legal document the patient record is defined as | record "generated at/for HCO as its business record & record that would be released upon request"
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| patient record can serve as a source of data for | research, programs, evaluation, education & public health studies
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| "report cards" | performance reports of HCOs
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| help consumer evaluate & select health plan | "report cards"
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| in order to record minimum info about a patient, early institutions used | ledgers
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| NY Hopsital was established in 1771, but only began recording | patient information around 1790
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| Penn. Hosptial est. 1792 in Philadephia with leadership of | Ben Franklin
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| Charity Hosp. in New Orleans entered 1st medical records in | large ledgers
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| when hospitals moved from ledgers to individual patient records they were | organized into systems that allowed easier retrieval of patient's record & data within document
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| early hospital records were | brief & contained carefully handwritten entries
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| some early hosptials filed the records according to | diseases or treatments, & some indexes to identify diseases & associate w/particular patient records
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| 1874 upon invention of typewritter, some lengthly handwritten docs were typed | operative reports & history/physical exams
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| ACS established minimum standards including specifications for content of patient record & | required certain activities to be documented in record within specific time frame
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| ACS helped form the professional organization | AHIMA
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| one chapter in within the Joint Commission accreditatio manuals is devoted to | information management
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| state licensing boards require HCF accredited by Joint Commission as well as | meet state licensing requirements to be authorized to provide health care services
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| voluntary Joint Commission accreditation review involved | standards at level/step up from state-mandated minimum requirements
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| at times state licensing requirements are more specific that | the Joint Commission standards
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| heavily influenced methods for documenting record & fast/accurate retrieval of doc for reimbursement | private health insurance & fenderal programs for insuring
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| insurance companies & MCO have increased quantity & specificity of documentation from patient record in order to | support each claim for hlth care services that is submitted for payment
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| due to 1965 added provisions to Social Security Act, instead of voluntary standards, | regulations were part of the federal Conditions for Participation
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| Conditions for Participation | regulations providers must follow for reimbursement of care given to patients using Medicare/Medicaid
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| ACS established minimum standards including specifications for content of patient record & | required certain activities to be documented in record within specific time frame
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| ACS helped form the professional organization | AHIMA
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| one chapter in within the Joint Commission accreditatio manuals is devoted to | information management
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| state licensing boards require HCF accredited by Joint Commission as well as | meet state licensing requirements to be authorized to provide health care services
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| voluntary Joint Commission accreditation review involved | standards at level/step up from state-mandated minimum requirements
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| at times state licensing requirements are more specific that | the Joint Commission standards
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| heavily influenced methods for documenting record & fast/accurate retrieval of doc for reimbursement | private health insurance & fenderal programs for insuring
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| insurance companies & MCO have increased quantity & specificity of documentation from patient record in order to | support each claim for hlth care services that is submitted for payment
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| due to 1965 added provisions to Social Security Act, instead of voluntary standards, | regulations were part of the federal Conditions for Participation
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| Conditions for Participation | regulations providers must follow for reimbursement of care given to patients using Medicare/Medicaid
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| "if it isn't documented, it wasn't done" mantra to attempt to communicate | importance of proper documentation in record under Medicare review program
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| one solution for attempting to control health care costs was to | move from fee-for-service to prospective payment method
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| prospective payment method | payment rate established in advance & reflect average of what service should cost
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| btwn 1980-2002 Congress moved to prospective payment method for | ambulatory surgery cntrs, inpatient ACH, skilled nursing facilities, home hlth agencies, outpatient hostpial services, inpatient rehab factilities & long-term care hospitals
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| primary patient record applied changing technology, however scans/images were | stored in separate area
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| increased reliance on HIT as means of staying competitive in information-intensive industry | personal computers & data communication tech entered marketplace
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| paper-based patient record converted into electronic format would be composed of | electronic databases containing hlth care info generated of patient while treated in given hlth care facility
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| IOM defined patient record of future as on that | "will reside in system significantly designed to support users by providing accessibility to complete & accurate, data, alerts, reminders, clinical support systems, links to medical knowldege & other aids"
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| if record computerized, researchers could access data in aggregate form when looking for a certain | treatment but no need to identify an individual patient
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| "public & private sectors join in establishing Computer-based Patient Record Institute to promote & facilitate development, implementation, & dissemination of CPR" | recomendation of 1989 IOM study to inprove patient records through use of information tech
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| to reduce hlth care costs, control medical/medication errors, reduce needless duplication of diagnostic tests, monitor public hlth & bioterroism concerns government should enable ways to develop 21st century EHR system | June 2004 President's Information Technology Advisory Committee(PITAC) published report
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| PITAC proposed framework for hlth care info infrastructure would be composed of | EHRs for all americans; computer-assisted clinical decision support; computerized provider order entry & secure private, interoperable, electronic hlth exchange
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| progress report from Office of National Coordinator for Health Information Technology (ONC) laid out | stratigic action to achieve vision of consumer-centric & information-rich health care
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| support efforts to implement EHRs & regional hlth information organizations to support an overall national hlth info infrastructure | ONC
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| has taken action-oriented role in facillitating adoption of HIT & EHR systems | federal goverment, in response to PITAC report & ONC progress report
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| evolved from need for accurate/complete records rgding care/treatment of patient as one means of improving/standarizing health care | HIM profession
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| ACS's standardization prorgam was catalyst for organizing & educating group of people who could | assist hospitals in meeting informational needs of accrediting bodies & medical educators
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| director of hospital activiteds at ACS & important leaders in hospital standardization movement | Dr Malcolm MacEachern
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| in 1928 Dr Malcolm MacEachern invited medical records workers to attend meeting of Clincal Congress of the ACS which resulted in | medical records workers organizing to form Association of Record Librarians of N. America (ARLNA)
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| first president of (ARLNA) | Grace Whiting Myers, Librarian Emeritus of Massachusetts General Hospital
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| (ARLNA) formed Board of Registration in 1933 which developed rules & regulations | which "certified" that an individual met certain criteria/standards entitling them to bear credential, registered record librarian (RRL)
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| AHIMA e-health Task Force, 2002 determined that skills HIM professionals | could easily transfer to e-health enviroment & they were suited to perform as profession transitions into e-HIM enviroment
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| the future state of hlth info is electronic, consumer-cenetered, comprehensive, longitudinal, eccessible, credible, & secure. ownership of hlth info is shared responsibility btwn consumer & provider | update to 2010 vision statement AHIMA e-HIM task for from Bloomrosen 2005
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| body of knowledge & practice that ensires availability of hlth info to facilitate real-time hlth care delivery & critical hlth-related decision making for mutliple purposes across diverse org, settings & disciplines | practice of HIM in 2010 defined as
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| moving towards virtual department; functions re-engineered/eliminated as processes for EHRs change | HIM department changes
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| HIM professionals work | wherever hlth data collected, organized, & analyzed
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| AHIMA advances role of HIM professionals through | support cutting-edge academic programs, offer certification/professional development opportunities, & engaging in key initiatives supporting HIM practice
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| 1932 cirriculum for medical record librarians was | finalized
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| early medical record librarian programs were | in hostpials & required 2-4 yrs college, some req graduation from approved nursing school
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| developed by ARLNA 1943 | Essentials of an Acceptable School for Medical Record Librarians
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| Essentials of an Acceptable School for Medical Record Librarians is | uniform standard for all medical record programs
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| ART programs transitioned to 2 & 4 yr college/univeristy settings in 1960's & 70's due to | profession's body of knowledge grew & expanded skills in work setting were required of program graduates
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| when AHIMA changed its name in 1991 college programs | changed their program names to HIM
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| standards that are basis for HIM program accreditation | Standards for Health Information Management Education
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| expertise hlth data calloction, analysis, monitoring, maintenance & reporting activites in accordance w/established data quality principles, legal/regulatory standards & professional best practices guidelines | Asoociates Degree HIM
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| expertise to develop, implement/manage individual, aggregate, & public hlth care data collection & reporting systems | Baaclaureate Degree HIM
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| executive level, enterprise-wide, administrative, research or applied health informantics activities | Master's Degree HIM
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| accreditation is defined as | voluntary, nongovernmental process that educational programs elect to participate in as a means of demostrating to public that program meets/exceeds stated standards of educational quality
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| Standards for Health Information Management Education was previously | Essentials of an Acceptable School for Medical Record Librarians
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| program accreditation standards of AHIMA represent | minimum requirements an education program must follow to acheive program accreditation
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| 2004 AHIMA established its own accrediting body | Commission on Accreditation for Health Informantics & Information Management Education (CAHIIM)
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| approval programs offered by AHIMA but not fall under responsibility of CAHIIM | Coding & Transcription
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| Coding & Transcription administered by | AHIMA Approval Committee for Certificate Programs
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| demostrating to public that program/orgranization meets/exceeds stated standards of quality | focus of accreditation
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| means of protectin public from individuals who haven't met standards of practice prescribed by given state or profession | licensure, certification, registration
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| credentialed individuals req to maintain credential over time by | meeting CEUs as defined by agency/organization that supports credential
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| licensure occurs at | state level & overseen seen by state licensing board/agency
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| most hlth professionals who treat/touch patients in some way are required | to be licensed by state in which they practice
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| HIM professional certification begain in 1933 when | AHIMA formed Board of Registration to set standards for its members
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| constructed from detailed job analysis studies of individuals working in the field | certification examinations
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| AHIMA's certifying body is | Council on Certification (COC)
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| COC is responsible for creating/maintaing | certification & recertification process
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