APPENDIX

*Health Information Professional obligations include an understanding of HIPPA and the terms Privacy, Confidentiality, Plagiarism, as well as professional behaviors that include gathering of a competent history and physical, documenting and presenting in a clear and timely manner, and avoiding the perpetuation of erroneous information (Chart Lore).

**Examples of different documentation based on Health Provider role or patient’s transition through the health system: Full History, Physical, Consultation, Progress Note, Allied Health Note, Documentation of preventative health services, Transfer Summaries. Different charting systems include paper-based formats and the electronic health record.

^†Examples of complex issues: multiple patient care issues including acute and chronic care needs, multiple pathophysiological processes and treatment effects; significant complexities in care systems including setting, ancillary needs