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,Certification
The process by which a duly authorized body evaluates and recognizes an individual,
institution, or educational program as meeting predetermined requirements.
Credential
A formal agreement granting an individual permission to practice in a profession, usually
conferred by a national professional organization dedicated to a specific area of
healthcare practice
Registration
The act of enrolling
Documentation
The recording of pertinent healthcare as a business record and form of communication
among caregivers
Ancillary services
Tests and procedures ordered by a physician to provide information for use in patient
diagnosis or treatment.
,Autopsy report
Written documentation of the findings from a postmortem pathological examination
Authentication
The process of identifying the source of health record entries by attaching a handwritten
signature, the authors initials, or an electronic signature
Deemed status
An official designation indicating that a healthcare facility is in compliance with the
Medicare Conditions of Participation
Care Plan
The specific goals in the treatment of an individual patient, amended as the patients
condition requires and the assessment of the outcomes of care; serves as the primary
source for ongoing documentation of the residents care, condition, and needs
Consent to treatment
Legal permission given by a patient or a patients legal representative to a healthcare
provider that allows the provider to administer care and treatment or to perform surgery
or other medical procedures.Mary works as a HIM manager in a clinical research facility.
Each month, she collects and analyzes data that has been collected from medical records
for her research purposes. Is the purpose of her data collection primary or
secondary?
Explain your reasoning. Then discuss common responsibilities of the health information
management professional for each purpose.
Discussion Rubric
, Electronic Health Record (EHR)
An electronic record of health related information on an individual that conforms to
nationally recognized interoperability standards and that can be created, managed, and
consulted by authorized clinicians and staff across more than one healthcare organization
Data collection tool
A paper or electronic form that contains all of the data elements to be collected in the
audit
Ambulatory
Treatment provided on an outpatient basis
Analysis
Review of health record for proper documentation and adherence to regulatory and
accreditation standards
Audit trail
A chronological set of computerized records that provides evidence of information
system activity (log ins and log outs, file accesses) used to determine security violations