A healthcare professional responsible for managing and organizing patient medical records, ensuring accuracy, confidentiality, and compliance with regulatory standards.
The practice of acquiring, analyzing, and protecting digital and traditional medical information vital to providing quality patient care.
Digital versions of patients’ paper charts, containing medical history, diagnoses, medications, treatment plans, immunization dates, allergies, radiology images, and laboratory test results.
The Health Insurance Portability and Accountability Act outlines rules and safeguards for protecting patients’ medical records and other personal health information.
The process of assigning numeric codes to diagnoses and procedures for billing purposes, ensuring accurate reimbursement from insurance companies and government programs.
The procedure for disclosing patients’ medical information to authorized parties while maintaining privacy and adhering to legal requirements.
The electronic sharing of patient medical information between different healthcare organizations, improving coordination of care and patient outcomes.
Reviewing medical records for accuracy, completeness, and compliance with regulatory standards to enhance patient care and organizational performance.
Knowledge of medical terminology, abbreviations, and acronyms essential for accurately interpreting and documenting patient information.
Implementing measures to safeguard patient medical records from unauthorized access, data breaches, and identity theft, maintaining confidentiality and trust in healthcare systems.