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Chapter 1: Healthcare Delivery Systems
Professional Organizations:
American Health Information Management Association (AHIMA)
Professional Organizations:
Centers for Medicare and Medicaid Services
(CMS)
Ownership
For-profit
Not-for-profit
Net Income
Board of Directors
Board of Directors members
Chief Executive Officer
(CEO)
Chief Operating Officer
(COO)
Chief Financial Officer
(CFO)
Chief Medical Officer
(CMO)
Chief Information Officer
(CIO)
Chief Medical Information Officer
(CMIO)
Chief of Staff
(COS)
Credentials
Accreditation:
The Joint Commission
Licensure
Compliance
Joint Commission:
Accreditation & Certification
National Patient Safety Goals
(NPSG)
Universal Protocol
Speak Up
Department of Health & Human Services
Chapter 2: Collecting Healthcare Data
Data
Information
Health data
Health Information
Aggregate data
Data Analytics
Assessment
Treatment
Mortality
Morbidity
Vital statistic
Epidemiology
Payer
Reimbursement
Medicare
Centers for Disease Control and Prevention
(CDC)
National Center for Health Statistics
(NCHS)
SOAP format
SOAP: Subjective
SOAP: Objective
SOAP: Assessment
SOAP: Plan of Treatment
Rule out
Outcome
Discharge
Diagnosis
Symptom
Health data
Demographic data
Socioeconomic data
Financial data
Guarantor
Clinical data
Attending physician
Primary Care Physician
Data base:
EHR, character, field, record, file
Data: character
Data: field
Data: records
Data: files
Electronic Health Record
(EHR)
Data consistency
Data accessibility
Data validity
Data accuracy
Data dictionary
Master Patient Index
(MPI)
Patient Account Number
Medical Record Number
Health Record
Medication Administration
Face Sheet
Physician's Order
Computerized Physician Order Entry
(CPOE)
Radiology
Authenticate
Electronic signature
Countersigned
Master Forms File
Integrated Record
Source-Oriented Record
Problem-Oriented Record
PROBLEM LIST
Medical Home Model
Data set
Inpatient
Outpatient
Uniform Bill (UB-04)
Uniform Hospital Discharge Data Set
(UHDDS)
Minimum Data Set
(MDS 3.0)
Outcome and Assessment Information Set
(OASIS)
ICD-10-CM
Reimbursement
Benchmarking
Health Insurance Portability and Accountability Act (HIPAA)
Chapter 3:
Hybrid Record
Point-of-care documentation
Interface
Admission
Encounter
History and Physical
(H&P)
Report
Digital Signature
Discharge Summary
Document Imaging
Indexing
Bar coding
Electronic Document Management System
(EDMS)
Clinical Decision Support System
(CDSS)
Evidence-based Decision Support
Order Sets
E-prescribing (eRx)
Evidence-based Medicine
(EBM)
Clinical Pathway
Coding
Analysis
Workflow
Algorithum
Data Repository
Data warehouse
Health Information Exchange
(HIE)
Meaningful Use
Private Sectors:
Health Level Seven (HL7)
Markle Foundation
Certification Commission for Health Information Technology (CCHIT)
Markle Foundation
Health Level Seven
(HL7)
Certification Commission for Health Information Technology
(CCHIT)
Interoperability
Office of the National Coordinator for Health Information Technology
National Health Information Network
(NHIN)
