Information Governance

Information governance (IG) ensures necessary policies, procedures, processes and controls implemented to manage the appropriate use of information.

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Clinical Document Improvement

The key purpose of Clinical Documentation Improvement (CDI) is concurrent review of the medical record to increase the accuracy, clarity, and specificity of provider documentation.  The CDI process ensures that diagnoses and procedures are supported by both documentation in the patient record and the assigned code on the bill.

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Electronic Health Record

An electronic health record (EHR) is a digital version of a patient’s paper chart. EHRs are real-time, patient-centered records that make information available instantly and securely to authorized users.

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Privacy and Security

Ensuring privacy and security of health information is a fundamental principle for the health information management (HIM) profession.

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