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  2. Health information management - Wikipedia

    en.wikipedia.org/wiki/Health_information_management

    Health information management's standards history is dated back to the introduction of the American Health Information Management Association, founded in 1928 "when the American College of Surgeons established the Association of Record Librarians of North America (ARLNA) to 'elevate the standards of clinical records in hospitals and other medical institutions.'" [3]

  3. 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 ...

  4. Registered health information administrator - Wikipedia

    en.wikipedia.org/wiki/Registered_Health...

    Seeing that each patient's medical record is complete, kept confidential, and safeguarded from individuals not involved with the medical care of the patient are primary responsibilities. [ 4 ] A RHIA certification is a preferred qualification for positions including health information management director, clinical documentation improvement ...

  5. Medical record - Wikipedia

    en.wikipedia.org/wiki/Medical_record

    The medical record serves as the central repository for planning patient care and documenting communication among patient and health care provider and professionals contributing to the patient's care. An increasing purpose of the medical record is to ensure documentation of compliance with institutional, professional or governmental regulation.

  6. Medical transcription - Wikipedia

    en.wikipedia.org/wiki/Medical_transcription

    Working in medical transcription leads to a mastery in medical terminology and editing, ability to listen and type simultaneously, utilization of playback controls on the transcriber (machine), and use of foot pedal to play and adjust dictations – all while maintaining a steady rhythm of execution. Medical transcription training normally ...

  7. 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.

  8. Medical scribe - Wikipedia

    en.wikipedia.org/wiki/Medical_scribe

    A medical scribe is an allied health paraprofessional who specializes in charting physician-patient encounters in real time, such as during medical examinations.They also locate information and patients for physicians and complete forms needed for patient care.

  9. Point of care - Wikipedia

    en.wikipedia.org/wiki/Point_of_care

    Point of care (POC) documentation is the ability for clinicians to document clinical information while interacting with and delivering care to patients. [10] The increased adoption of electronic health records (EHR) in healthcare institutions and practices creates the need for electronic POC documentation through the use of various medical devices. [11]

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