Chapter 8: Health Information Management and Protection

Workers compensation

Employer insurance for treatment of an employees injury or illness related to the job.

Protected health information (PHI)

Individually identifiable personal health information as defined by HIPAA. Information that can be linked to a particular individual by name, code, or number is PHI.

Reverse chronological order

Items placed with oldest first.

Demographic data

Relating to the statistical characteristics of populations.

Problem oriented medical record (POMR)

A common method of compiling information that lists each problem of the patient, usually at the beginning of the folder, and references each problem with a number throughout the folder.

Clearinghouse

A company that receives, reviews, sends, and manages insurance claims for physicians.

Narrative

A paragraph indicating the contact with the patient, what was done for the patient, and the outcome of any action.

Present illness

A specific account of the chief complaint, including time frames and characteristics.

SOAP

A style of charting that includes subjective, objective, assessment and planning notes.

Covered entity

Anyone required to follow the Health Insurance Portability and Accountability Act's requirements. Health care providers, insurance companies, and insurance clearing houses are covered entities.

Subject filing

Arranging files according to their title, grouping similar subjects together.

Numeric filing

Arranging files by a numbered order.

Alphabetic filing

Arranging of names or titles according to the sequence of letters in the alphabet.

Flow sheet

Color coded sheets that allow information to be recorded in graphic or tabular form for easy retrieval; form that gathers all the important data regarding a patients condition and stays in the patients chart as a reminder of care and a record of whether care expectations have been met.

Electronic health records (EHRs)

Information about patients that is recorded and stored on a computer.

Health Information Technology for Economic and Clinical Health (HITECH) Act

Law enacted as part of the American Recovery and Reinvestment Act of 2009 to promote the adoption and meaningful use of health information technology.

Chief complaint

Main reason for the visit to the medical office.

Cross reference

Notation in a file telling that a record is stored elsewhere and giving the reference; verification to another source; checking the tabular lost against the alphabetic list in ICD-9 coding.

Microfilm

Photographs of records in a reduced size.

Chronological order

Placing in the order of time; usually the most recent is placed foremost.

Medical history forms

Record containing information about a patients past and present health status.

Microfiche

Sheets of microfilm.