RHIT Exam Definition set

383 terms by mkduff 

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Interdisciplinary patient care plan

The special form or view that plays the central role in planning and providing care at nursing, psychiatric, and rehabilitation facilities

case-mix index (entire facility)

[SUM(Relative Weight * # of Pt w/ that MS-DRG)] / Total # of Pt

Nationally uniform conversion factor

A numerical factor (dollar amount) used to multiply or divide a quantity when converting from one system of units to another. Determined annually by the legislature and published in the Federal Register, it is used by Medicare to make adjustments according to the changes in the cost of living index.

Joint Commission Accredited Facilities

Hospitals, Hospital-based ambulatory care, Freestanding ambulatory care, Managed Care, Correctional Facilities, Mental Health & Substance Abuse,

Direct Correlation

A positive relationship between two variables. Ex; Height & Weight, the taller one gets, the heavier they get.

Inverse Correlation

A negative relationship between two variables.

Net Autopsy Rate

(Total autopsies on InPt deaths for a period x 100)/
(Total InPt deaths - Unautopsied Corner/ME cases)

Critical Pathways

display goals for patients and provide the corresponding ideal sequence and timing of stqaff actions to achieve those goas with optimal efficiency.

Responsibilities for Planning & Implementing Clinical Quality Assessment programs

-Identify potential clinical quality problems
-Determine method for studying potential problems
-Participate in regular departmental meetings across the organization

Sentinel Event

A serious patient incident that should have a root cause analysis prepared

Avedis Donabedian

Advocated the assesment of healthcare from 4 perspectives:
Structure, Process, Outcome, and Cost

Total Quality Management

(1986)A management philosophy developed by W. Edwards Deming encouraging industrial organizations to focus on the quality of their products as their paramount mission as an alternative to authoritarian, top-down managment philosophies.
Further adapted by J.M. Juran & Philip Crosby

3 Computer sizes

Mainframe, Minicomputer, & Microcomputer

personal digital device

a handheld device used for computing, faxing, and networking

Administrative Information Systems

Patient Registration System
Financial Information System
Materials Management System

confidentiality

The expectation that information that an individual shares with a health care provider during the course of care will be used only for its intended purpose is referred to as _____

data security

The protection and tools that safeguard information and information systems is referred to as _____

data dictionary

A descriptive list of the data elements to be collected in an information system or database whose purpose is to ensure consistency of terminology

AHIMA Data Quality Management Model

[Application] the purpose for which the data are collected [Collection] the processes by which data elements are accumulated [Warehousing] and [Analysis] the process of translating data into information utilized for an application

Application

(In the AHIMA Data Quality Managment Model) the purpose for which the data are collected

Collection

(In the AHIMA Data Quality Managment Model) the processes by which data elements are accumulated

Warehousing

(In the AHIMA Data Quality Managment Model) processes and systems used to archive data and data journals

Analysis

(In the AHIMA Data Quality Managment Model) the process of translating data into information utilized for an application

Data Quality Characteristics

Accessibility, Accuracy, Consistency, Comprehensiveness, Currency, Definition, Granularity, Relevancy, Precision, Timeliness

longitudinal medical record

a single patient record that maintains health care information throughout a patient's lifetime

Joint Commission

Requires one record for each patient; entries made by authorized persons; preoperative and final diagnoses; and thorough documentation of all procedures

Freestanding Nursing Facility

A facility or a portion of a facility licensed by the state as a nursing facility where the majority of patients are regarded as permanent residents for long-term nursing care
Nursing home, Long-term care facility, Intermediate care facility

Freestanding Skilled Nursing Facility

A facility or a portion of a facility licensed by the state as a skilled nursing facility and certified, either wholly or in part, as a Medicare Part A skilled nursing facility provider.
Skilled nursing facility, Skilled nursing unit, Distinct part Medicare SNF unit

Acute Care Hospital

A designated area, attached wing, or a separate structure on the hospital campus that is licensed for skilled nursing care
Skilled nursing facility, Skilled nursing unit, SNF unit

Long-term Acute Hospital

A facility providing specialized acute care for patients averaging a LOS of 25 days or more

healthcare clearinghouse

a public or private entity (e.g., billing service, repricing company, etc...) that processes or facilitates the processing of health information received from another entity (e.g., provider, third-party payer, and so on) from a nonstandard into a standard format.

privacy officer

oversees all ongoing activities related to the development, implementation, maintenance of, and adherence to the organization's policies and procedures covering the privacy of, and access to, patient health information in compliance with federal and state laws and the health care organization's information privacy practices.

Title II: HIPAA Administrative Simplification

... require the DHHS to establish national standards for electronic health care transactions and national identifiers for providers, health plans, and employers. It also addresses the security and privacy of health data. Adopting these standards will improve the efficiency and effectiveness of the nation's health care system by encouraging the widespread use of electronic data interchange in health care.

Management By Objective

The process of setting objectives in the organization to give a sense of direction to the employees is called...

5 Functions of Management

The most widely accepted are ... given by KOONTZ and O'DONNEL:
Planning, Organizing, Staffing, Directing and Controlling.
http://www.managementstudyguide.com/management_functions.htm

Planning

Koontz & O'donnel's 5 Functions of Management
The basic function of management. It deals with chalking out a future course of action & deciding in advance the most appropriate course of actions for achievement of pre-determined goals. According to KOONTZ, "Planning is deciding in advance - what to do, when to do & how to do. It bridges the gap from where we are & where we want to be".

Organizing

Koontz & O'donnel's 5 Functions of Management
The process of bringing together physical, financial and human resources and developing productive relationship amongst them for achievement of organizational goals.
-Identification of activities.
-Classification of grouping of activities.
-Assignment of duties.
-Delegation of authority and creation of responsibility.
-Coordinating authority and responsibility relationships.

Staffing

Koontz & O'donnel's 5 Functions of Management
The function of manning the organization structure and keeping it manned.
-Manpower Planning (estimating man power in terms of searching, choose the person and giving the right place).
-Recruitment, selection & placement.
-Training & development.
-Remuneration.
-Performance appraisal.
-Promotions & transfer.

Directing/Leading

Koontz & O'donnel's 5 Functions of Management
Actuates the organizational methods to work efficiently for achievement of organizational purposes.
-Supervision
-Motivation
-Leadership
-Communication

Controlling

Koontz & O'donnel's 5 Functions of Management
Implies measurement of accomplishment against the standards and correction of deviation if any to ensure achievement of organizational goals.
a) Establishment of standard performance.
b) Measurement of actual performance.
c) Comparison of actual performance with the standards and finding out deviation if any.
d) Corrective action.

OASIS data are used to assess the ___ of home health services.

Outcome

Policy

A statement or guideline that directs decision making or behavior is called a:

Returned Overpayments

Examples of high-risk billing practices that create compliance risks for healthcare organizations include all of the following, except:

Federal Sentencing Guidelines

Corporate compliance programs became common after adoption of which of the following:

Accreditation

The act of granting approval to a healthcare organization based on whether the organization has met a set of voluntary standards

The Joint Commission

Accrediting organization has instituted continuous improvement and sentinel event monitoring and uses tracer methodology during survey visits?

The Joint Commission

This organization has been responsible for accrediting healthcare organizations since the mid 1950's and determines whether the organization is continually monitoring and improving the quality of care they provide.

The Deficit Reduction Act of 2005:

Made compliance programs mandatory

The Joint Commission

The largest healthcare standards-setting body in the world?

Physician Offices

Do not have to meet standards in the Conditions of Participation

Elements of performance

Specific performance expectations and/or structures and processes that provide detailed information for each of the Joint Commission standards are called:

Health Care Quality Improvement Act

mandated by the creation of the National Practitioner Data Bank

Medical Staff Bylaws

Dictates how the medical staff operates?

Chief Executive Officer

Responsible for implementing the policies and strategic direction of the hospital or healthcare organization and for building an effective executive management team

Data Security

The protection measures and tools for safeguarding information and information systems

A written contingency plan

required by HIPAA standards

Administrative safeguards

are policies and procedures required by HIPAA that address the management of computer resources and security

Employees

the biggest threat to the security of healthcare data

Utilization Review

The process of determining whether the medical care provided to a specific patient is necessary according to preestablished objective screening criteria

Physical Control

Placing locks on computer room doors type of security control

Conditions of Participation

general name for Medicare rules affecting healthcare organizations

During user acceptance testing of a new EHR system, physicians are complaining that they have to use multiple log-on screens to access all system modules. For example, they have to use one log-on for CPOE and another log-on to view laboratory results. One physician suggest having a single sign-on that would provide access to all the EHR system components. However, the hospital administrator thinks that one log-on would be a security issue. What information should the HIM director provide?

Single sign-on is less frustrating for the end user and can provide better security

Physical Access Controls

security safeguards that protect equipment, media, and facilities

Audit Trail

a software program that tracks every access to data in the computer system

Cost Control

The one aspect of managed care that has had the greatest impact on healthcare organizations

Evidence-based practice guidelines

an explicit statement that directs clinical decision making

Safe Harbors

Exceptions to the Federal Anti-Kickback Statute that allow legitimate business arrangements and are not subject to prosecution

Commission on Accreditation of Rehabilitation Facilities

This private, not-for-profit organization is committed to developing and maintaining practical, customer-focused standards to help organizations measure and improve the quality, value, and outcomes of behavioral health and medical rehabilitation programs.

Deemed Status

accrediting bodies such as The Joint Commission can survey facilities for compliance with the medicare Conditions of Participation for Hospitals instead of the government

Tracer Methodology

Joint Commission survey methodology involves an evaluation that follows the hospital experiences of past or current patients

Information Security

Case management coordinates an individual's care, especially in complex and high cost cases. Goals of case management include all of the following except:

ABN

When a service is not considered medically necessary based on the reason for encounter, the patient should be provided with this form indicating that Medicare might not pay and that the patient might be responsible for the entire charge.

Social Security Number

The number that has been proposed for use as a unique identification number but is controversial because of confidentiality and privacy concerns

Controlled Vocabulary

necessary to ensure that each term used in an EHR has a common meaning to all users

Electronic document management system

a transition strategy to achieve an EHR

Patient Number

the unique identifier in the relational database patient table

Implementation Plan

A step-by-step approach to installing, testing, training, and gaining adoption for an EHR

CPOE

an application that uses standard order sets and other clinical decision support that supports physician order entry into the computer

Electronic point-of-care charting

Electronic systems used by nurses and physicians to document assessments and findings

User training

A key element in effective systems implementation

Portal

A special web page that offers secure access to data

Client/server

some computers are used primarily to enter data and others to process data the architecture is called:

Interoperability

The ability to electronically send data from one electronic system to a different electronic system and still retain its meaning

Identity Matching Algorithim

The key for linking data about an individual who is seen in a variety of care settings

Physician

The primary user of computerized provider entry

Mainframe

uses a single large computer to process data received from terminals into which data are entered

Electronic document management system

A transition technology used by many hospitals is to increase access to medical record content

Dual Core strategy

a hospital develops its EHR system by selecting one vendor to provide financial and administrative applications and another vendor to supply the clinical applications

Transaction processing system

information system used for processing patient admissions, employee time cards, and purchase orders

Planning

The first phase of the SDLC

Transmitters, receivers, media, and data

basic components make up every electronic network communications system

Direct cutover

The most common approaches to converting from an old information system to a new one are the parallel approach, the phased approach, and the ____ approach.

Planning

phase of the systems development life cycle is the primary focus on identifying and assigning priorities to the various upgrades and changes that might be made in an organization's information systems

Implementation

phase of the systems development life cycle are trial runs of the new system conducted, backup and disaster recover procedures developed, and training of end users performed

Relational database

stores data in predefined tables consisting of rows and columns

Primary Key

uniquely identifies each record in a database table?

Train-the-trainer

An organization identifies key people in various functional areas to be trained first, and then asks them to subsequently train other users in this same functional area.

Network

connects computers together in a way that allows for the sharing of information and resources

Server redundancy

reduce the risk that information is not accessible during a server crash

A system that enables processing of diagnostic studies results into tables, graphs, or other structure is:

Results retrieval and management technology

Community Hospital's hardware has been placed on back-order; the network team is having trouble getting the network to function properly. This is an example of:

Issues management

Audit logs and alert pop-ups are examples of:

Metadata

Which of the following is a family of standards that aid the exchange of data among hospital systems and physician practices?

HL7

The following descriptors about the data element PATIENT_LAST_NAME are included in a data dictionary: definition: legal surname of the patient; field type: numeric: field length: 50; required field: yes; default value: none; input mask: none. Which of the following is true about the definition of this data element?

The field type should be changed to Character

Systems testing of a new information system should be conducted using:

Actual Patient Data

Which of the following are used to associate relationships between entities (tables) in a relational database?

Foreign Keys

Which of the following security controls are built into a computer software program?

Application Controls

Community Hospital is identifying strategies to minimize the security risks associated with employees leaving their workstations unattended. Which of the following solutions will minimize the security risk of unattended workstations?

Implement session termination

OASIS data are used to assess the ___ of home health services.

Outcome

The Deficit Reduction Act of 2005:

Made compliance programs mandatory

Which of the following statements best defines utilization management?

It is a set of processes used to determine the appropriateness of medical services provided during specific episodes of care

Which of the following is not a type of utilization review?

Peer review

Which of the following is not one of the basic functions of the utilization review process?

Claims management

The Medical Review Committee wants to determine if the hospital is in compliance with Joint Commission standards for medical record delinquency rates. The HIM Director has compiled a report that shows that records are delinquent for an average of 29 days after discharge. Given this information, what can the Committee conclude?

Data are insufficient to determine whether the hospital is in compliance

Which of the following is the largest healthcare standards-setting body in the world?

The Joint Commission

Which of the following is the largest healthcare standards-setting body in the world?

The Joint Commission

Community Hospital wants to offer information technology services to City Hospital, another smaller hospital in the area. This arrangement will financially help both institutions. In reviewing the process to establish this arrangement, the CEO asks the HIM director if there are any barriers to establishing this relationship with regard to HIPAA. In this situation, which of the following should the HIM director advise?

City Hospital should obtain a business associate agreement with Community Hospital

Which of the following facilities do not have to meet standards in the Conditions of Participation?

Physician offices

An audit trail may be used to detect which of the following:

Unauthorized access to a system

Specific performance expectations and/or structures and processes that provide detailed information for each of the Joint Commission standards are called:

Elements of performance

The creation of the National Practitioner Data Bank was mandated by the:

Health Care Quality Improvement Act

Which of the following dictates how the medical staff operates?

Medical Staff Bylaws

Who is responsible for implementing the policies and strategic direction of the hospital or healthcare organization and for building an effective executive management team?

Chief Executive Officer

Medical school graduates must pass a test before they can obtain a _____ to practice medicine.

License

Under HIPAA rules, when an individual asks to see his or her own health information, a covered entity:

Can deny access to psychotherapy notes

In which of the following situations must a covered entity provide an appeals process for denials to requests from individuals to see their own health information?

When a licensed healthcare professional has determined that access to PHI would likely endanger the life or safety of the individual

Which of the following statements is true in regard to responding to requests from individuals for access to their PHI?

A cost-based fee may be charged for making a copy of the PHI

Which of the following is not an automatic contgrol that helps preserve data confidentiality and integrity in an electronic system?

Security awareness program

Within the context of data security, protecting data privacy means defending or safeguarding:

Access to information

The protection measures and tools for safeguarding information and information systems is a definition of:

Data Security

To date the HIM department has not charged for copies of records requested by the patient. However, the policy is currently under review for revision. One HIM committee member suggests using the copying fee established by the state. Another committee member thinks that HIPAA will not allow for copying fees. What input should the HIM director provide?

Base charges on the cost of labor and supplies for copying and postage if copies are mailed

A risk analysis is useful to:

Identify security threats

Which of the following is required by HIPAA standards?

A written contingency plan

Which of the following are policies and procedures required by HIPAA that address the management of computer resources and security?

Administrative safeguards

What is the biggest threat to the security of healthcare data?

Employees

To ensure relevancy, an organization's security policies and procedures be reviewed at least:

Once a year

Which of the following is not true of good electronic forms design?

Use radio buttons to select multiple items from a set of options

What committee usually oversees the development and approval of new forms for the health record?

Use radio buttons to select multiple items from a set of options

The process of determining whether the medical care provided to a specific patient is necessary according to preestablished objective screening criteria is:

Utilization Review

Placing locks on computer room doors is considered what type of security control?

Physical control

Which of the following is recommended for design of forms for an EDMS?

24 lb. paper for double-sided forms

The HIM Supervisor suspects that a departmental employee is accessing the EHR for personal reasons but has no specific data to support this suspicion. In this case, what should the supervisor do?

Ask the security officer for audit trail data to confirm or disprove the suspicion.

Coding policies should include which of the following elements?

AHIMA Standards of Ethical Coding

The Medicare Integrity Program was established as part of Title II of HIPAA to battle fraud and abuse and is charged with which of the following responsibilities?

Payment determinations and audit of cost reports

An individual designated as an inpatient coder may have access to an electronic medical record to code the record. Under what access security mechanism is the coder allowed access to the system?

Role-based

A secretary in the Nursing Office was recently hospitalized with ketoacidosis. She comes to the health information management department and requests to review her health record. Of the options here, what is the best course of action?

Allow her to review her record after obtaining authorization from her

St. Joseph's Hospital has a psychiatric service on the sixth floor of the hospital. A 31-year old male has come to the HIM department and requested to see a copy of his medical record. He indicated he was a patient of Dr. Schmidt, a psychiatrist, and that he was on the sixth floor of St. Joseph's for the last two months. These records are not psychotherapy notes. Of the options here, what is the best course of action?

Allow the patient to access his record if, after contacting his physician, his physician does not think it will be harmful to the patien

Minors are basically deemed legally incompetent to access, use or disclose their health information. What resource should be consulted in terms of who may authorize access, use, or disclose the health records of minors?

State law because HIPAA defers to state laws on matters related to minors

If an HIM department acts in deliberate ignorance or in disregard of official coding guidelines, it may be committing:

Fraud

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