| A | B |
|---|
| assembly | arranging the documents of the medical record in a specified order after discharge of the patient |
| authorization | a signed consent of the patient or his or her representative to release confidential information |
| compromise care | to make the patient's care less effective |
| contract service | a company hired to perform a function when the HIM department isunable to manage the amount of work |
| discharge summary | a report dictated by a physician at the end of hospitalization that details the diagnoses and treatment given |
| indexing | assigning a document to the correct patient,document type, and episode of care in an optical imaging system |
| loose documents | documents received by the HIM dept. after the patient has been discharged, that must be placed in the record |
| operative report | report dictated by a surgeon detailing the surgical procedure and findings |
| optical imaging system | computer system in which the documents are converted to computer images to insure that they are legible and have been indexed correctly |
| scanning | process of converting a paper document into a computer image |
| third party | a person or entity, such as an insurance company, other than the healthcare facility or patient |
| senior medical record clerk functions: | analysis and working in the physician incomplete area |
| file cleck functions: | pulling records, fining and refiling documents,create file folders for new patients,assemble records into final format,more... |
| accredited record technician(ART) | 2-yr program requires performing tasks in actual HIM dept.Then, you can be a coder, cancer registrar, supervisor or assistant HIM director in hospital |
| Registered Record Administrator (RRA) | 4-yr collage.You can be super, HIM dept. director, administrator.Can work for accounting firms that monitor efficiency of healthcare facility departments |
| Consultant | ARTS and RRAs with experience may be HIM consultants:coding, HIM dept. review and assessment,implementation of computer systems,HIM dept. management |
| Certified Coding Specialist | certification given by the AHIMA (American Health Information Management Association) |
| Educator | ARTs and RRAs can become teachers of HIM courses or conduct seminars |
