Health information management and coding practice
We support coding review with structured clinical notes, code lookup and signed records, keeping professional judgement with the people responsible for the record.
Set by American Health Information Management Association
What is built
- Structured clinical documentation brings relevant encounter information into the note.
- Clinicians can look up ICD-10 and CPT codes by name or number.
- Clinical notes can be completed as coded, signed records.
- The medical record retains the patient context for review.
- Claims and approvals use the selected Care plan’s coded clinical information.
What your auditor or regulator sees
A reviewer can examine the clinical note, recorded coding and signature alongside the patient context and relevant claim information. These are records for professional review, not an AHIMA approval mark. The facility’s clinicians and information-management team must assess whether the documentation accurately supports the recorded diagnoses, procedures and subsequent use of the information.
How the record supports your review
AHIMA provides professional guidance for health information management, ethical coding and documentation integrity. This page uses that practice context to explain the Care evidence available. It does not describe a single software conformance standard, an AHIMA certification or a licence to publish proprietary guidance inside the application.
Start with a representative consultation and inspect the structured information, the signed note and the codes selected. Lookup helps a professional find a code; it does not establish that the code is supported by the record. Automatic code suggestions, automated coding and denial prediction are not part of the confirmed Care scope.
Where insurance work is relevant, review Claims and approvals within Care Clinics Pro or Care Hospitals. The clinical record and claim context should be examined together, but a generated claim is not proof of coding accuracy or payer acceptance. The facility remains responsible for its documentation review and coding decisions.
Bring an example in which the narrative needs clarification before coding. Use the demonstration to inspect the available record and discuss the organisation’s review process, without assuming an unverified clinical documentation query workflow exists. The aim is an understandable evidence trail for qualified reviewers, not the removal of their judgement.
What we claim, precisely
The system holds the evidence; the facility's accountable person attests. Nothing here asserts that a facility is compliant.
Common questions
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No AHIMA software certification or endorsement is claimed. This page describes documentation and coding evidence relevant to professional information-management practice, with review and accountability retained by your organisation.
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No. The confirmed capability is code lookup by name or number. The clinician or coding professional must decide whether a selected code is supported by the clinical documentation.
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Claims and approvals are included in Care Clinics Pro and Care Hospitals. Structured documentation and coding review should be demonstrated within the Care plan and workflow your facility intends to use.
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No. A signature and coded record provide evidence for review, but the content still needs professional assessment. Documentation quality and code selection remain responsibilities of the appropriate facility team.
Preparing for AHIMA
Open the sandbox and look at the readiness view, or ask us to walk it against your own standard set.