RHIT key terms

The portion of a patient's health information that an organization designates, through written policy, as its official business record for care delivery, legal matters, and disclosure purposes.

A database that assigns each patient a unique identifier and links all of that patient's encounters across the organization, helping prevent duplicate records and wrong-patient errors.

A reference describing each data element in a system, including its name, definition, format, allowed values, and source, so staff interpret and report the data consistently.

The policies, roles, and decision processes that assign accountability for data quality, data definitions, access, and appropriate use across the organization.

The electronic sharing of patient information among separate providers and systems, or the organization that operates the network making that sharing possible.

A policy stating how long each type of record and data set must be kept and when lawful destruction may occur, based on legal, regulatory, and business requirements.

A program in which specialists review provider documentation to confirm it completely and accurately describes the patient's condition and care, supporting quality reporting, continuity, and correct code assignment.

Individually identifiable health information created, received, maintained, or transmitted by a covered entity or business associate in any form or medium. Employment and education records are generally excluded.

The HIPAA principle that uses, disclosures, and requests for health information be limited to the least amount reasonably needed for the purpose, with exceptions such as treatment and patient-authorized requests.

A signed permission from a patient or personal representative allowing use or disclosure of health information for a purpose HIPAA does not otherwise permit, such as marketing or most research.

A listing a covered entity must provide on request of certain disclosures of health information made in the prior six years, showing date, recipient, and purpose, with defined exceptions such as treatment and payment.

The duty to notify affected individuals, federal regulators, and sometimes the media when unsecured health information is impermissibly acquired, accessed, or disclosed, generally within 60 days of discovery.

The three activities for which HIPAA allows use and disclosure of health information without authorization: care delivery, billing and collection, and administrative functions such as quality and compliance.

A contract requiring a vendor that handles protected health information on behalf of a covered entity to safeguard that information and meet applicable HIPAA privacy and security requirements.

Removing identifiers from health data so it no longer identifies an individual, either by stripping the 18 HIPAA identifiers or by an expert's statistical determination that re-identification is very unlikely.

A required assessment of threats and vulnerabilities to electronic protected health information that organizations use to select reasonable safeguards and document the basis for security decisions.

The process of handling requests for patient information by verifying the requester's authority, confirming permission, disclosing only what is allowed, and documenting the disclosure.

A central store that combines data copied from many operational systems, cleaned and organized for reporting and analysis rather than for day-to-day transactions.

A database that collects defined data about a specific population or condition, such as a cancer or trauma registry, to support quality improvement, reporting, and research.

Comparing an organization's own performance or data with internal targets, peer organizations, or national norms to identify gaps and set improvement priorities.

A measure tracked over time that shows how well an organization is meeting a critical objective, such as denial rate, record completion time, or infection rate.

Using historical data and statistical models to estimate the likelihood of future events, such as readmission, disease onset, or missed appointment risk.

The process of recording the services, supplies, and procedures provided to a patient so they can be billed; missed or inaccurate capture causes lost revenue and compliance exposure.

The average relative weight of a hospital's inpatient discharges under a diagnosis related group payment system; a higher index reflects greater resource use and usually higher payment.

Medicare Severity Diagnosis Related Group: a classification that assigns inpatient stays to groups based on principal diagnosis, procedures, and complications, producing a fixed payment per stay.

Software that reviews claims for missing data, invalid codes, and payer-specific edits before submission, reducing denials and rework.

The ongoing process of tracking, appealing, and correcting claims that payers reject or refuse to pay, and analyzing patterns so the same errors stop recurring.

The percentage of claims accepted by payers on first submission without rejection or a request for more information; a common gauge of revenue cycle efficiency.

A measure of how long it takes on average to collect payment after services are billed, calculated by dividing total receivables by average daily revenue or charges.

An organized set of written policies, training, monitoring, auditing, and reporting channels that an organization uses to prevent, detect, and correct violations of law and payer requirements.

A federal statute that penalizes individuals and organizations that knowingly submit false or fraudulent claims to government payers, and that lets whistleblowers sue and share in recoveries.

A settlement document in which an organization accepts defined compliance duties, such as audits, training, and reporting, under outside monitoring for a set period after a fraud matter is resolved.

A federally contracted reviewer that examines Medicare claims to find improper payments, recovering overpayments from providers and returning underpayments to them.

A federal law that makes it a crime to knowingly offer, pay, solicit, or receive anything of value to induce referrals of items or services paid for by federal health care programs.

The structured methods used to prepare, support, and guide staff through a new process or system so the change is adopted and performance is sustained.

A planning tool that lists an organization's internal strengths and weaknesses alongside external opportunities and threats, providing a structured basis for setting strategy.

A repeating improvement method in which a team plans a small change, carries it out, studies the results, then acts by adopting, adapting, or abandoning the change.

The gap between planned and actual revenue or expense, reported as a dollar amount and a percentage, used to monitor financial performance and explain departures from plan.

Identifying and developing employees who can step into key roles when current leaders leave, limiting disruption and preserving institutional knowledge.