CEHRS key terms

The portion of a patient's health information that an organization designates as its official business record and that can be released in response to a valid request.

A chronological record of who accessed or changed electronic health information, when the action occurred, and what was viewed or modified.

A written policy listing how long each category of health record must be kept and the approved method for destroying it once that period ends.

Documentation added to a health record after the original time of care, clearly dated when written and labeled to show it was not entered at the time of service.

The accuracy, completeness, and consistency of health information over its lifecycle, protected by controls that prevent unauthorized alteration or accidental loss.

A maintained summary of a patient's active and significant health conditions, used to support care decisions, reporting, and accurate code assignment.

A patient-requested change or addition to health information that the provider reviews and either accepts, denies with a written explanation, or documents as disputed.

The process of reviewing records for missing signatures, incomplete fields, or late reports so the record meets organizational documentation standards before finalization.

The HIPAA principle that a covered entity should use, disclose, or request only the amount of protected health information needed to accomplish the intended purpose.

A written permission from a patient or personal representative that allows a covered entity to release specified protected health information to a named recipient, including an expiration date.

A report a covered entity must provide on request that lists certain disclosures of protected health information made outside treatment, payment, and health care operations, with dates and recipients.

The required process of informing affected individuals, regulators, and sometimes the media when unsecured protected health information is accessed or disclosed without authorization.

The three core activities-treatment, payment, and health care operations-for which protected health information may be used or disclosed without patient authorization under HIPAA.

A written statement given to patients that explains how their health information may be used and disclosed, their rights, and the organization's privacy duties.

The process of removing specified identifiers from health information so it no longer identifies an individual, either through safe harbor removal or expert statistical determination.

The authorized process of disclosing a patient's health record to a requesting party after verifying the request, consent or authorization, and applicable legal requirements.

HIPAA regulations that require administrative, physical, and technical safeguards to protect the confidentiality, integrity, and availability of electronic protected health information.

A standardized code set maintained by the American Medical Association that describes medical services and procedures for billing and reimbursement purposes.

A standardized diagnosis code set used in the United States to report patient conditions on claims and support public health, quality, and research reporting.

A code set used for billing supplies, equipment, drugs, and some services, including Level II codes for items not represented in CPT.

A two-character code added to a procedure code to clarify details such as laterality, multiple providers, or a distinct service that affects payment.

Software that checks claims for missing data, coding conflicts, and payer-specific rules before submission, helping reduce denials and rework.

The process of reviewing rejected or denied claims, identifying the cause, correcting the claim or documentation, and resubmitting or appealing within payer deadlines.

The patient's share of covered health care costs after the deductible is met, usually expressed as a percentage of the allowed amount.

The amount a patient must pay out of pocket for covered services before an insurer begins paying its share of the allowed charges.

The process of recording services, supplies, and procedures delivered to a patient so they can be translated into billable charges on a claim.

A database that assigns a unique identifier to each patient and stores demographic details, used to link records and prevent duplicate or fragmented charts.

The process of confirming with a payer that a patient's insurance plan is active on the date of service and covers the planned care.

Rules that determine which insurance plan pays first when a patient has coverage under more than one plan, preventing duplicate payment.

The person responsible for paying a patient's bill, who may be the patient or another party such as a parent or legal representative.

The policyholder or employee through whom health insurance coverage is obtained; the subscriber may or may not be the patient receiving care.

A unique ten-digit identifier assigned to health care providers and organizations in the United States for use in standard electronic transactions.

A payer's advance approval requirement for certain services, drugs, or equipment, confirming medical necessity before care is delivered.

A digital version of a patient's chart that supports real-time documentation, order entry, results review, and information sharing across care settings.

The ability of different health information systems to exchange data and allow clinicians to use the shared information meaningfully across organizations and settings.

An organized network that allows participating providers to share patient health information electronically across different EHR systems and organizations.

Tools built into an EHR that provide alerts, reminders, order sets, or reference information to help clinicians make safer and more effective care decisions.

The degree to which health data is accurate, complete, timely, and consistent, making it reliable for clinical care, reporting, and quality measurement.

A structured database that collects defined patient data, often for a specific condition or population, to support quality reporting, tracking, and outcomes improvement.

A security control that grants staff access only to the health information needed for their job duties, reducing the risk of inappropriate viewing or disclosure.