Health Record and Documentation Flashcard

Front

What is one of the likely contents of a health record?

Back

Patient's medical history

Front

What is the role of a clinical documentation specialist?

Back

To document patient care accurately

Front

Role of health information management?

• Cooking meals for patients
• Managing patient data and records
• Designing hospital buildings
• Cleaning medical equipment

Back

Managing patient data and records

Front

What is a key difference between a medical coder and a medical transcriptionist?

Back

Medical coders assign codes to diagnoses and procedures.

Front

What is considered the backbone of healthcare systems, hospitals, clinics, and healthcare provider offices?

Back

Health records and health information systems

Front

What is the role of professionals in health information management?

Back

To acquire, analyze, and protect digital and traditional health information

Front

What does HIM stand for in the context of healthcare?

Back

Health Information Management

Front

What is the permanent file set up by doctors and hospitals for every patient they treat commonly known as?

Back

Health record or chart

Front

What information is typically included in a patient's health record or chart?

Back

Medical history and test results

Front

What is one of the uses of health records in the context of insurance?

Back

To provide background for private insurance claims