| A | B |
|---|
| Data Quality | How well data meets criteria for accuracy, completeness, and fitness for its intended purpose. |
| Fitness for Intended Purpose | The extent to which data serves the specific needs of an organization or user. |
| Data Accuracy | The degree to which data is correct and reflects the real-world situation it represents. |
| Data Completeness | The degree to which all required data elements are present. |
| Data Consistency | The degree to which data is recorded in the same way across records and systems. |
| Data Timeliness | The degree to which data is available when needed and recorded within an appropriate time frame. |
| Data Relevance | The degree to which data meets the current or future needs of users. |
| Data Integrity | The accuracy, consistency, and reliability of data throughout its lifecycle. |
| Reliability | The degree to which data can be trusted and depended on for use. |
| Health Information Management Professional | A professional who supports data quality, documentation standards, and health information practices. |
| Data Governance Framework | A structure of roles, policies, and processes used to manage and protect data. |
| Data Validation | The process of checking data to ensure it is accurate, complete, and meets expected requirements. |
| Data Cleansing | The process of correcting or removing inaccurate, incomplete, or duplicate data. |
| Data Audit | A review of data to identify errors, gaps, or quality concerns. |
| Data Assessment | An evaluation of data quality, reliability, and usefulness. |
| Data Quality Standard | An established expectation used to guide the accuracy, completeness, and consistency of data. |
| Data Quality Policy | An organizational rule that supports the creation and maintenance of high-quality data. |
| Records Management | The supervision and administration of records throughout their lifecycle. |
| Legal Compliance | Following laws and regulations that apply to health information and records. |
| Regulatory Compliance | Following rules, standards, and requirements set by regulatory bodies. |
| Privacy Requirement | A rule that protects personal health information from unauthorized access, use, or disclosure. |
| Billing and Coding | Processes that rely on accurate documentation to support payment and classification of services. |
| Clinical Documentation Standard | An expected requirement for recording patient care information clearly and accurately. |
| Patient Safety | Protection of patients from harm, supported by accurate and complete documentation. |
| Quality of Care | The standard of healthcare provided to patients, supported by reliable health information. |
| Operational Efficiency | The ability of an organization to work effectively with minimal wasted time or resources. |
| Searchability | The ability to locate records or information efficiently. |
| Records Retrieval | The process of locating and accessing records when needed. |
| Records Retention | Keeping records for the required length of time based on policy and legislation. |
| Records Disposal | The approved removal or destruction of records after retention requirements are met. |
| Strategic Planning | Long-term planning supported by accurate and reliable data. |
| Decision Support | The use of data and records to support informed decisions. |
| Quality Assurance (QA) | A formal process used to monitor and improve data quality. |
| Quantitative Analysis | Reviewing health records to evaluate completeness, accuracy, and required content. |
| Qualitative Analysis | Reviewing documentation quality, consistency, and compliance with policies or legislation. |
| Patient Record Review | The process of examining a health record to identify missing, incomplete, or inaccurate information. |
| Deficiency | A missing, incomplete, or incorrect item in a health record. |
| Deficiency Tracking | Recording and monitoring incomplete documentation until it is corrected. |
| Incomplete Chart | A patient chart missing required documents, information, or authentication. |
| Chart Assembly | Organizing record information into an acceptable and consistent format. |
| Logical Order | Arranging documentation in a consistent sequence that supports understanding and use. |
| Hybrid Records System | A record system that includes both paper and electronic records. |
| Mandatory Form | A required document that must be present in the health record when applicable. |
| Consent Form | A document showing patient agreement to care, treatment, or information sharing. |
| Advanced Directive | A legal tool that records a person’s wishes for care if they cannot make or communicate decisions. |
| Death Certificate | An official document confirming a person’s death and related required information. |
| Authentication | Verification that documentation was completed or approved by the responsible provider. |
| Physician Document | A required document completed or authenticated by a physician. |
| Organizational Document | A required document created or maintained according to organizational policy. |
| Health Records Department | The department responsible for managing, storing, reviewing, and maintaining health records. |
| Documentation Quality | The clarity, accuracy, completeness, and usefulness of healthcare documentation. |
| Continuity of Care | Ongoing coordinated care supported by accurate and accessible patient information. |
| Care Team Communication | The sharing of accurate information among healthcare providers involved in patient care. |
| Clinical Outcome | The result of healthcare provided to a patient. |
| Clinical Documentation Improvement (CDI) | A program or process used to improve the accuracy and completeness of clinical documentation. |
| Comorbid Condition | An additional medical condition present at the same time as a primary condition. |
| Specificity | The level of detail needed in documentation to accurately describe a patient’s condition. |
| Acronym | A shortened form made from the first letters of words. |
| Abbreviation | A shortened form of a word or phrase. |
| Ambiguous Abbreviation | An abbreviation that can have more than one meaning and may cause confusion. |
| Approved Abbreviation | An abbreviation accepted by an organization for safe use in documentation. |
| Documentation Requirement | A rule or expectation about what must be recorded in the health record. |
