This unique number is assigned to each patient to prevent duplicate records.
What is Medical Record Number (MRN)
Providers must complete this process to ensure all required documentation is finished after a visit.
What is chart completion
This is the main patient chart in Epic where clinical information is stored.
What is Chart Review
“Cardio‑” refers to this part of the body.
What is the heart
This federal law protects the privacy and security of patient health information.
What is HIPAA
This type of error occurs when two different patients’ records are accidentally combined.
What is an overlay
This type of documentation is required to authenticate entries in the medical record.
What is a provider signature
This Epic tool helps staff find patients using name, DOB, or MRN.
What is Patient Lookup
“Neuro‑” refers to this body system.
What is the nervous system
This document explains how a patient’s information may be used or disclosed.
What is the Notice of Privacy Practices
This type of error occurs when one patient ends up with more than one medical record number.
What is a duplicate
When documentation is missing or unclear, HIM may issue one of these to the provider.
What is a deficiency or query
This Epic feature allows providers to electronically sign their documentation.
What is In Basket or electronic signature
“Hepato‑” refers to this organ.
What is the liver
This HIM function ensures the accuracy and completeness of the medical record.
What is data quality management
The process of correcting patient identity errors and ensuring accurate demographic data.
What is patient identity management
This term refers to the timeframe providers have to complete their charts before they become delinquent.
What is the chart completion deadline
This Epic module is used to manage patient identity issues such as duplicates.
What is Identity or Patient Merge
“-ectomy” refers to this type of procedure.
What is surgical removal
This process ensures only authorized individuals can access patient information.
What is access control
This national standard helps ensure accurate patient matching across systems.
What is the USCDI (United States Core Data for Interoperability)
This HIM process ensures the record is complete, accurate, and finalized before billing.
What is record validation or chart analysis
This Epic function allows HIM to track incomplete documentation and provider deficiencies.
What is Chart Completion or Deficiency Tracking
"Tachy-" means
What is fast or rapid
This term refers to information that can identify a patient, such as name or date of birth.
What is PHI (Protected Health Information)