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  2. Release of information department - Wikipedia

    en.wikipedia.org/wiki/Release_of_Information...

    ROI departments perform such tasks as obtaining patient consent, certifying medical records, and deciding what information can be released. The ROI department is often found within the health information management services (HIMS) department of a hospital. The oversight of the HIMS department is usually overseen by a director.

  3. Health information management - Wikipedia

    en.wikipedia.org/wiki/Health_information_management

    The patient health record is the primary legal record documenting the health care services provided to a person in any aspect of the health care system. The term includes routine clinical or office records, records of care in any health related setting, preventive care, lifestyle evaluation, research protocols and various clinical databases.

  4. Clinical documentation improvement - Wikipedia

    en.wikipedia.org/wiki/Clinical_documentation...

    Clinical documentation improvement (CDI), also known as "clinical documentation integrity", is the best practices, processes, technology, people, and joint effort between providers and billers that advocates the completeness, precision, and validity of provider documentation inherent to transaction code sets (e.g. ICD-10-CM, ICD-10-PCS, CPT, HCPCS) sanctioned by the Health Insurance ...

  5. Medical scribe - Wikipedia

    en.wikipedia.org/wiki/Medical_scribe

    The difference between AI medical scribes and human scribes, who physically accompany healthcare providers during patient visits, AI scribes typically operate in the background usually on the providers device. AI medical scribes although do parts of the job description of a traditional medical scribe, cannot do everything.

  6. Medical transcription - Wikipedia

    en.wikipedia.org/wiki/Medical_transcription

    An individual who performs medical transcription is known as a medical transcriber (MT) or a Medical Language Specialist (MLS). The equipment used is called a medical transcriber, e.g., a cassette player with foot controls operated by the MT for report playback and transcription.

  7. Clinical coder - Wikipedia

    en.wikipedia.org/wiki/Clinical_coder

    Clinical coder - Wikipedia

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