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Clinical documentation improvement (CDI), also known as "clinical documentation integrity", is the best practices, processes, technology, people, and joint effort between providers and billers that advocates the completeness, precision, and validity of provider documentation inherent to transaction code sets (e.g. ICD-10-CM, ICD-10-PCS, CPT, HCPCS) sanctioned by the Health Insurance ...
Health information management's standards history is dated back to the introduction of the American Health Information Management Association, founded in 1928 "when the American College of Surgeons established the Association of Record Librarians of North America (ARLNA) to 'elevate the standards of clinical records in hospitals and other medical institutions.'" [3]
AHIMA describes its foundation as a sister organization to the Association for Healthcare Documentation Integrity (AHDI) and states the foundation has a charitable and educational nature. The foundation formulates and issues opinions, supports education, conducts research and compiles its contributions into the AHIMA BoK ( body of knowledge ).
Moreover, as far as patient health records are concerned, there are always potential threats of information leakages, data hacking, information destruction, manipulation or even blackmailing of patients by the external or internal users. Since the consequences of Information leaks are comparatively high in contrast to information alterations ...
The 2018 Verizon Protected Health Information Data Breach Report (PHIDBR) examined 27 countries and 1368 incidents, detailing that the focus of healthcare breaches was mainly the patients, their identities, health histories, and treatment plans. According to HIPAA, 255.18 million people were affected from 3051 healthcare data breach incidents ...
A hospital information system (HIS) is an element of health informatics that focuses mainly on the administrational needs of hospitals.In many implementations, a HIS is a comprehensive, integrated information system designed to manage all the aspects of a hospital's operation, such as medical, administrative, financial, and legal issues and the corresponding processing of services.
The information contained in the medical record allows health care providers to determine the patient's medical history and provide informed care. The medical record serves as the central repository for planning patient care and documenting communication among patient and health care provider and professionals contributing to the patient's care.
Various health care facilities had instigated different kinds of health information technology systems in the provision of patient care, such as electronic health records (EHRs), computerized charting, etc. [104] The growing popularity of health information technology systems and the escalation in the amount of health information that can be ...