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Registered health information administrator ( RHIA ), previously known as registered record administrator, is a professional certification administered by the American Health Information Management Association (AHIMA) in the United States. Passing the exam results in certification for health information management .
Clinical Coder. A clinical coder —also known as clinical coding officer, diagnostic coder, medical coder, or nosologist —is a health information professional whose main duties are to analyse clinical statements and assign standardized codes using a classification system. The health data produced are an integral part of health information ...
In nursing education, a clerkship refers to the clinical courses conducted by students during their final year of studies. The student satisfaction with the clerkship is a determinant factor in selection of nursing field. [9] [10] Physician assistant programs in the United States used the term in the same manner. [11] [12] [13]
Health information management ( HIM) is information management applied to health and health care. It is the practice of analyzing and protecting digital and traditional medical information vital to providing quality patient care. With the widespread computerization of health records, traditional (paper-based) records are being replaced with ...
Records management, also known as records and information management, is an organizational function devoted to the management of information in an organization throughout its life cycle, from the time of creation or receipt to its eventual disposition. This includes identifying, classifying, storing, securing, retrieving, tracking and ...
A medical record includes a variety of types of "notes" entered over time by healthcare professionals, recording observations and administration of drugs and therapies, orders for the administration of drugs and therapies, test results, X-rays, reports, etc. The maintenance of complete and accurate medical records is a requirement of health ...
A release of information (ROI) department or division is found in the majority of hospitals. In the United States, HIPAA and state guidelines strongly direct the rules and regulations of patient information. ROI departments perform such tasks as obtaining patient consent, certifying medical records, and deciding what information can be released.
Medical transcription, also known as MT, is an allied health profession dealing with the process of transcribing voice-recorded medical reports that are dictated by physicians, nurses and other healthcare practitioners. Medical reports can be voice files, notes taken during a lecture, or other spoken material.
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