Written and graphic information documenting facts and events during the rendering of patient care. Records must be comprehensive and data must be accurately documented.

Individual who works in a facility in the health information management department and is responsible for handling and safeguarding patient medical records such as medical records file clerk, health information management (HIM) professional, registered health information administrator (RHIA), and registered health information technician (RHIT).

Organization that promotes the development and acceptance of electronic health care record systems.

Permanent, legal document (letter or report format) that formally states the results of the patient’s examination or treatment.

1. Evaluation of services by contractor medical personnel; includes analysis of claims data to identify potential billing problems resulting in inappropriate utilization situations; includes various plans of action to correct the problem. 2. In the Medicaid program, an analysis by a team composed of physicians and other appropriate health and social service personnel may be required to assess the patient’s condition and need for care (e.g., medical evaluations of inpatients in a long-term care facility). Also called continued stay review . 3. In the Medicare program, an evaluation by a Medicare administrative contractor and/or quality improvement organization (QIO) of services rendered by health care providers. This assessment is done to determine if the services are reasonable and necessary; services meet Medicare guidelines; quality of service is in line with the standards of health care; services are medically appropriate in an inpatient, outpatient, or other setting; and services are supported by documentation. Also called utilization review .

Type of tax-free savings account that allows individuals and their employers to set aside money to pay for health care expenses. An employer can set up an MSA for his or her employees and make an annual contribution to the MSA, which is tax deductible for both employer and employee. MSA balances accumulate from year to year tax-free, but unused funds may not be carried over in a flexible spending account (FSA) (another type of MSA). Earned interest is not taxed. MSAs are portable, allowing individuals to take their MSAs with them when they change jobs or relocate. Medicare beneficiaries are eligible to enroll in a similar tax-advantaged savings account, which may be referred to as a Medicare medical savings account . See dependent-care spending account .

An authorization from the employer that is given to the physician, either written or verbal, to treat the injured or ill employee.