Chapter 3

4. A collection of care information related to a specific disease, condition, or procedure that makes health record information available for analysis and comparison.
7. Shows the format in which the data will be displayed.
8. A chronological set of computerized records that provides evidence of information system activity used to determine security violations.
10. Raw facts and figures.
12. Uses the codes assigned to determine the diagnostic-related group or another grouping.
15. Additional information provided in the health record.
16. The unstructured narrative data that are the result of a person typing data into an information system.
17. Provides general direction about the design of the form.
18. Assigns the diagnosis and procedure codes.

1. The information, understanding, and experience that give individuals the power to make informed decisions.
2. Data that have been turned into something meaningful.
3. The permanent record of all patients treated at a healthcare organization.
4. Tells the HIM department the name, health record number, date of request, name of requester, and where the health record needs to be delivered.
5. The process of extracting and analyzing large volumes of data from a database for the purpose of identifying hidden and sometimes subtle relationships or patterns and using those relationships to predict behaviors.
6. Fixed rules that must be followed.
9. Contains information relating to the physical or mental health or condition of an individual.
11. A clarification made to healthcare documentation after the original document has been signed.
13. An inquiry process aimed at discovering new information about a subject or revising old information.
14. The linking of patient name, health record number, document type, and other identifying information to the scanned document.
19. When a patient has more than one health record number at different locations within an enterprise or healthcare organization.