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HIM Terminologies




Abbreviated Injury Scale (AIS)

A set of numbers used in a trauma registry to indicate the nature and severity of injuries by body system.


An ability (achievement) test

Tests used to assess the skills an individual already possesses.



Brief summary of the major parts of a research study.



The process of recording known transactions in the appropriate time before cash payments or receipts are expected or due.


Allied health professionals performance review

Similar to the review for nursing staff, other allied health professionals, licensed and unlicensed, must provide evidence of ,maintenance of credentials and the ability to appropriately follow delineated procedure in their area of expertise in the healthcare organization.


Alternative hypothesis

A hypothesis that state that there is an association between independent and dependent variables.



Ambulatory care

Preventive or corrective healthcare services provided on a nonresident basis in a provider’s office, clinic setting, or hospital outpatient setting.


Ambulatory care center (ACC)

A healthcare provider or facility that offers preventive, diagnostic, therapeutic, and rehabilitative services to individuals not classified as inpatients or residents.



Ancillary systems

Electronic systems that generate clinical information (such as laboratory information systems, radiology information systems, Pharmacy information systems, and so on).


Certified in healthcare privacy and security (CHPS)

Credential that recognizes advanced competency in designing implementing, and administering comprehensive privacy and security protection programs in all type of healthcare organizations: requires successful completion of both the CHP and CHS exams (jointly sponsored by AHIMA and HIMSS).


Certified medical transcriptionist (CMT)

A certification that is granted upon successful completion of an examination.


Children’s Health Insurance Program (CHIP)

The children’s healthcare program implemented as part of the balanced budget Act of 1997; formerly known as the state children’s Health Insurance Program or SCHIP.




An itemized statement of healthcare services and their costs provided by a hospital, physician office, or other healthcare provider; submitted for reimbursement to the healthcare insurance plan by either the insured party or the provider.


Claims data

Information required to be reported on a healthcare claim for service reimbursements.

Clinic outpatient

A patient who is admitted to a clinical service of a clinic or hospital for diagnosis or treatment on an ambulatory basis.

Clinical analytics

The process of gathering and examining data in order to help gain greater insight about patients.


Clinical Care Classification(CCC)

Two interlaced taxonomies, the CCC of Nursing Interventions and Action, that provide a standardized framework for documenting patient care in hospitals, home health agencies, ambulatory care clinics, and other healthcare settings.


Clinical care plan

Care guidelines created by healthcare providers for individual patients for a specified period of time.

Clinical communication space

The context and range of electronic and interpersonal information exchanged among staff and patients

Clinical Data

Data captured during the process of diagnosis and treatment


Clinical data specialist

Specialist who concentrates on ensuring accurate and complete coding. Validating the information contained in databases for internal and external uses and providing information for clinical research across the entire integrated healthcare delivery system.



References: Health Information Management book, AHIMA PRSS 233 N. Michigan Ave, 21st fl .Chicago, IL 60601, (800)335-5535, www.ahima.org