A record that resides in an electronic system specifically designed to support users by providing accessibility to complete and accurate data, alerts, reminders, clinical decision support systems, links to medical knowledge and other aids.
HIM professionals are frequently involved in both the design and implementation states of an electronic health record.
A patient is transferred to a long term care facility, what does this tell you about the patient.
The patient is no longer in need of acute care but does need continued nursing service in a facility.
is directly tied to the ability of the facility to attract patients and receive reimbursement.
Belonging to one's professional association is an important way of
finding current information and learning about changes in one's chosen field.
Refers to the delegation of health care operations from internal production of a business to an external entity that specializes in an operation.
1965 Ammended Social Security Act provided 2 government subsidized health care programs...
Medicare - persons over the age of 65
Medicaid - Persons who are poor or impoverished
Continuum of care
refers to matching an individuals ongoing needs with the appropriate level and type of care.
What has proven to be the most relevent to the development of treatments to improve or cure disease.
The connection between cause and effect.
An external entity has reviewed the program of study to determine if the program meets certain predetermined standards.
Ambulatory health care
A patient goes in for minor surgery and is discharged within 24 hrs, what type of care is best described by this scenario.
What is the focus of E-HIM
The electronic health data and the manner in which it is collected, validated, stored and disseminated.
In today's health care environment, the focus has changed from
records management to include data manipulation and information management.
HIM professionals working in a correctional facility would notice the greatest difference in
Increased involvement with the judicial system.
HIM professionals working in a home health care agency would need to be familiar with the data elements of the
OASIS / Outcome and Assessment Information Set used for medicare reporting.
List the three electronic health information management initiatives.
To promote the transition from a paper-based to an electronic health information infrastructure.
To reinvent the manner in which institutional and personal health information is managed.
To deliver measurable cost and quality results from improved information management.
If a patient is scheduled for abdominal surgery, what type of consent would be required before the operation.
A patient requests to see his health care record, what are his rights in this scenario?
The patient has the right to access his own information.
A subpoena duces tecum is best described as
a command to produce books, documents, and other physical items.
No, this is considered physician self referal
A physician's brother owns and operates a local clinical laboratory, and has asked his brother to help him out by referring patients to him when he orders his lab work. Is this legal?
If a patient requests an accounting of disclosures made by the health care provider, the provider has _____days to act upon the request.
Identity theft is
the knowing transfer or use, without lawful authority, of the identity of another person with the intent to commit, aid, or abet any unlawful activity that constitutes a violation of federal, state, or local law.
An employee notices that upcoding is being done by her department. When she reports this to the appropriate authority, she is then called a ...
Three examples of individual identifiers protected under HIPAA are:
social security numbers, dates: of birth, or admission or discharge, address and telephone numbers, email addresses, photographs, IP addresses
T/F Code of ethics are binding agreements that are written specifically for each professional area.
What does the principle of minimum necessary standard govern? What is required of the healthcare provider?
The principle of minimum necessary staindard governs the release of patient specific information. The health care provider is required to make reasonable efforts to limit the patient - specific health information disclosed to the least amount necessary to accomplish the intended purpose of the use, disclosure, or request.
Document executed while patient is competent that provides direction as to medical care the patient should receive in the event they are incapacitated or unable to make personal decisions.
Behaviors showing Elements of ethics
Treats others with respect, keeps commitments, inspires the trust of others, works with integrity, models ethical behavior, upholds the values of the organization, arrives on time for work, does not go beyond prescribed breaks, respects the property of others, etc.
MPI Master Patient Index
A listing or database of all the patients treated by a health care facility, indexed according to an indentification process.
Health Care Data uses
evidence of patient care, indicate quality of patient care, support educational efforts,support research, support compliance efforts, support reimbursement, support planning efforts of governmental entities, support employment decisions, support public health efforts, verify disabilities.
Three main groups that share responsibility for the Health Care organization's compliance with the requirements for collecting and maintaining clinical data are
The healthcare provider, The HIM professional, Health Care organization's health record committee.
The Healthcare providers
provide patient care and document the care rendered in a manner which is accurate, complete, and clinically pertinent.
administer policies uniformly and develop procedures to facilitate completion of incomplete records and compliance with external and internal standards.
Health care organizations Health record committee
sets the organization's standards for quality of the healthcare record, including the terminology and abbreviations which will be used.
Advantages of an electronic health record over a paper based Health record
-paper record is static where a database is not,
-paper record can only be in one place at one time whereas a database may be accessed from multiple locations.
-paper record has a fixed order for organizing the data whereas a database can retrieve data in different sorting orders and be selective based on user criteria.
-paper record makes the viewer browse multiple pages searching for data whereas a database allows almost instant access to the latest available and valid data.
Quality Health Care means
doing the right thing at the right time, in the right way, for the right person, and getting the best possible results.
Achieving quality in health care management is the result of the
dedication of a variety of professionals in all levels of employment and in all aspects of health care.
To make the PPS Prospective payment system work
Medicare adopted the Diagnosis Related Group or DRG.
A model that is a classification system which groups patients who are medically related by diagnosis, treatment, length of stay, age, and sex
initiative by JCAHO where performance data is used to examine a healthcare organization's internal performance over time and to compare organization's performance with that of others.
two patients are scheduled for the same time slot when using the computer scheduling system
is an effective tool for analysis of population characteristics by inference from sampling.
What is the percentage of increase in workload if a provider was seeing 20 but now sees 30 patients a day?
A graph that presents the frequency of data through the use of a circle drawn and divided into sections that correspond to the frequency in each catagory.
A payment methodology that is set by a formula for a set amount regardless of quantity or nature of services rendered.
HIPAA Transactions Rule
HIPAA rule that requires covered entities who transmit certain patient data electronically to use specific electronic transactions and code sets.
a vocabulary that specializes in words or phrases of a clinical or medical nature
The words, their pronunciation, and the methods of combining them that has been established by long usage and understood by the medical profession
a chosen set of words, usually arranged in alphabetical order, understood and accepted by a community
actions taken to establish, protect, promote, and improve the quality of health care.
steps a group would follow using the FOCUS PDCA in chronological order
1-find a process to improve
2-organize a team that knows the process
3-clarify the current knowledge of the process
4-understand the causes of special variation
5-select the process improvement
diagram that organizes information into a visual pattern to show the relationship between factors in a problem
Pert (Program evaluation and review technique)
tool used to track activities according to a time sequence, showing the interdependence of activities
graph with statistically generated upper and lower control limits used to measure key processes over time
nominal group technique
organizes ideas wherein a list of ideas are labelled alphabetically and then prioritized.
identifies major categories of factors which influence an effect and the sub factors within each category; also called the fish-bone or Ishikawa diagram.
Medicare Part B
covers physician fees, outpatient hospital services, and home health care services for those over 65 years of age
Areas of knowledge/skills of a good coder
-knowledge and understanding of biomedical sciences, information technology, health care data content and structure, health care delivery systems, and reimbursement methodologies.
-possess skill with the coding schemes employed most commonly in the United States today (ICD-9-CM and CPT)
HL7 develops specifications that allow different health care software applications within an organization to communicate with one another.
The X12 develops specifications for communication between software applications. It differs in that the focus is on developing a national standard for exchanging business information so as to facilitate business-to-business operations.
is a data set mandated by the federal government for those facilities treating Medicare and Medicaid patients. Since virtually all short-term general hospitals treat Medicare and Medicaid patients, the UHDDA has become the standard for reporting.
Six graphing rules that apply to most situations
1-the graph should be self-explanatory
2-the scale used should be easily readable
3-if more than one curve or line is displayed on a single graph for comparison purposes, the curves or lines should be differentiated from each other
4-the starting point of the graph should be clearly marked
5-the independent and dependent variables should be plotted on the generally accepted axis (the independent variable on the X-axis and the dependent variable on the Y-axis)
6-an accuracy check should be conducted for each graph created
What employees are exempt from the minimum wage provisions of FLSA (Federal Labor Standards Act)
If the employee is paid a salary rather than a wage
Steps of the disciplinary process
4-suspension without pay
6-termination of employment
Directing others includes
continuous process of decision making, instructing others, and giving orders.
involves the employers decision to end a person's employment and are the result of the employer's choice.
is central to all business due to the magnitude and frequency of changes that occur in today's environment. All companies want to stay viable must anticipate and respond to these changes.
What three factors must be present for the study to be a true experimental design?
an investigator has a hypothesis and conducts research then interprets the data to build a theory
Motivators in the workplace
opportunities for personal or professional growth, achievement, autonomy, advancement, responsibility, recognition
role of OSHA
The federal act sets mandatory standards for safety and health for all employees. It requires employers to operate a place of employment that is free from recognized hazards that are likely to cause serious injury or a fatality
Federal law offers protections against age discrimination to workers who are over what age?
40 years old
Leaders with positional power would be
noted on the organizational chart, but leaders with personal power would not always be
Epidemiologists have started to focus their attention as it is the fastest growing problem in the United States
chronic and degenerative diseases
The reliability of data means the accuracy of a measurement and whether the measurement represents reality.
refers to the repeatability of a measurement. The measurement is evaluated to see if the conditions of measurement were standardized.
Health Care Informatics
concentrates on how to use technology to facilitate acquiring, processing, interpreting, and communicating health care data
a group formally designated by an institution to safeguard the rights and welfare of human subjects
data aggregation study
involves the collection of data from large numbers of medical records with out focusing on direct patient contact
as a result of the Hawthorne studies, managers became more aware of the need to focus on social relationships in the workplace
The ADA (Americans with Disabilities Act)
applies to employees, job applicants, customers, and visitors
variation or deviation
a manager analyzes and compares data against the standard set for an activity, when standards are not met this data is called...
the participant is not informed but the clinician knows which participants have been assigned to receive the experimental intervention
neither the patient nor the clinicians involved are aware of which participants have been assigned to receive the experimental intervention.
in response to medical research abuses, the National Commission published what many consider the landmark document in the area of human subject research ethics
healthcare information systems
cover a broad range of applications, serving both clinical and administrative functions
a method used to measure an organization's level of preparedness to prevent and recover from a disaster
An independent contractor
is an individual who agrees to perform certain work according to his own means, manner, and methods of performance
IRB's must be at least five members
and are comprised of individuals affiliated with the institution sponsoring the IRB, at least one member must NOT be affiliated with the institution
the use of electronic communications and information technologies to provide or support clinical care at a distance
force field analysis
a tool used to prioritize ideas, applicable to identifying and visualizing the relationships of significant influencing forces
An idea-generation method in which the root causes of a problem are discovered by asking the question "why" at least five times in a given discussion
software programs that use branching logic to arrive at the most accurate diagnosis-related-group
limited data set
a form of data in which direct identifiers have been removed, but other data such as city, state, or zip codes, dates of service, birth, and death remain.
unseen information in common text files, which can indicate when a document was created or revised and can contain edits, notes, or other private data
an ethical concept referring to the prohibition against doing harm; operates through the obligation to prevent evil or harm
nosocomial infection rate
the number of hospital based infections divided by the total number of discharges (including deaths)
diseases that affect many persons in a community, area, region at the same time, arising from a common source and clearly in excess of normal expectancy
a data set that classifies values but does not require a logical ordering of those values
a data set that is ordered, though the differences between the values are not important
a theory of wealth distribution in which the wealth in any country is held by a few, while the majority of its citizens struggle for the remaining dollars. Commonly known as the 80/20 rule
a form of analysis used to identify strengths, weaknesses, opportunities, and threats an organization may have in relation to the marketplace
most complex level of medical and surgical care available, often provided at university or research institutions
the belittling or criticizing of the skills, knowledge, or qualifications of another professional
an ethical decision making theory based on moral rules and unchanging principles that are derived from reason and can be applied universally sometimes referred to as formalism or duty orientation