Medical Records Key Terms

Know key terms when working with electronic or paper medical records

Medical records possess all the needed information about a patient, including illnesses, insurance information, a health summary, complaints and treatments. The management and handling of these records fall under certain restrictions and guidelines. Medical professionals use a language, both verbal and written, specific to the medical community. Codes and abbreviations are common in medical records, and medical office and billing staff must understand the basic key terms found in most patient records.

HIPAA

HIPAA is an act signed into law in 1996. The Health Insurance and Portability and Accountability Act helps protect patient medical records and privacy. It governs how medical offices utilize patient records, and a patient-signed copy of the HIPAA privacy rule notice should be in every patient's file.

Electronic medical records

Electronic medical records (EMR) allow for faster retrieval of records when dealing with patients in the office and over the phone. An EMR program can manage patients, billing codes, disease codes, insurance information and clinical aspects of a medical office.

Coding

Coding refers to the practice of assigning letters and numbers to a specific disease or billing procedure. A large part of a patient's medical records will involve medical coding. While there are medical coding professionals, anyone dealing with medical records must be familiar with common codes.

ICD-9 and ICD-9-CM

ICD stands for the International Classification of Diseases. It's commonly used to record mortality data from death certificates. However, ICD-9 and ICD-9-CM are codes governed by the World Health Organization. These codes govern all diseases, surgical, diagnostic and therapeutic procedures. It's very common when working with medical records to be asked the ICD-9 code when talking with other offices or insurance companies.
Centers for Disease Control and Prevention.

Continuity of care record

The continuity of care record is all the pertinent information about a patient. Medical professionals can electronically forward these records to other offices to ensure patients receive continuous care without having to wait for medical offices to mail records or call doctors.

Clinical messaging

Clinical messaging is an automated system that lets patients schedule appointments, change appointments, cancel appointments, request prescriptions refills and leave a message for the doctor, all without having to talk with the medical staff. The information is automatically recorded in the medical records. Clinical messaging is still in the alpha stage in the medical community, but experts predict that more offices will take advantage of it.

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