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Flashcards to review for the RHIA Examination.

Source-Oriented Health Record

Documents organized into sections according to the provider's and departments that provide treatment (lab together, rad. together, clinical notes together)

Problem-Oriented Health Record

Divided into four parts: database, problem list, initial plan, progress notes (SOAP)

SOAP what does S stand for?

Subjective (patient's point of view)

SOAP what does O stand for?

Objective (what the practitioner finds)

SOAP what does A stand for?

Assessment (combine subjective and objective to make a conclusion)

SOAP what does P stand for?

Plan (approach to be taken to resolve patient's problem

Integrated Health Records

Documentation from various sources organized in strict chronological or reverse chronological order

Advantage of Integrated Health Record?

Easy to follow course of diagnosis and treatment

Disadvantage of Integrated Health Record?

Difficult to compare similar information (ex. lab results or oncology information)

When should H&P be documented in record?

Within 24 hours of admission

When should Operative Report be documented in record?

Immediately following surgery

When should Verbal Orders be cosigned?

Within 24 hours

When should Discharge Summary be documented?

Immediately after discharge of patient

Qualitative Analysis

Review of record to ensure that standards are met and determine the adequacy of entries documenting the quality of care

Quantitative Analysis

A review of health record to determine its completeness and accuracy

Data Accuracy

Data are the correct values and are valid

Data Accessibility

Data items are easily obtainable and legal to collect

Data Comprehensiveness

All required data items included AND entire scope of data is collected and intentional limitations documented

Data Consistency

Value of data is reliable and consistent across applications

Data Currency

Data is up to date, if it is outdated it must have been up to date at the time it was presented

Data Definition

Clear definitions provided so users know what data means, each data element should have clear meaning and accepted values

Data Granularity

The attributes and values of data should be defined at the correct level of detail

Data Precision

Data values should be just large enough to support the application or process and acceptable values or ranges must be defined

Data Relevance

The data are meaningful to the performance of the process or application for which they are collected

Data Timeliness

Determined by how the data are being used and their context

Minimum Data Set (MDS) purpose?

Promote comparability and compatibility of data by using standard data items with uniform definitions

Uniform Hospital Discharge Data Set (UHDDS)

Uniform collection of data on inpatients

Uniform Ambulatory Core Data Set (UACDS)

Improve ability to compare data in ambulatory care settings

Minimum Data Set (MDS) for Long-Term Care (LTC) and Resident Assessment Instrument (RAI)

Comprehensive functional assessment of long-term care patients

Outcome and Assessment Information Set (OASIS)

Comprehensive assessment for adult home care patient and forms the basis for measuring patient outcomes

Uniform Clinical Data Set (UCDS)

Data collection utilized by peer review organization to determine the quality of patient care

Data (3 definition points)

1. Collection of elements on a given subject
2. Raw facts and figures expressed in text, numbers, symbols, and images
3. Facts, ideas, or concepts that can be captured, communicated, and processed, either manually or electronically

Information (2 definition points)

1. Data that have been processed into meaningful form, manually or by computer in order to be valuable to user
2. Adds to a representation and tells recipient something that was not known before

Data Model

Plan or pattern for an information system, including the database structure, known as a conceptual model, and the translation of the concept to the computer, known as the physical model

Database Entities

Persons, locations, things, or concepts about which data can be collected and stored

Database Attribute

Describes an entity or distinct characteristics about it

Database Relationship

Associations between entities

Database Character

Collection of bits make up a byte


A character such as a number, letter, or symbol

Database Field

Made up of several characters such as name, age, or gender

Database Record

Made up of a series of fields about one person or thing

Database File

Made up of fields and records about an entity such as a patient

What is another word for file or entity


What are fields in a database table?


What are records in a database table?


Relational Model Database

Database management system in which data are organized and managed as a collection of tables

Object Oriented Database Model

Uses commands that act as small, self-contained instructional units (objects) that may be combined in various ways

Hierarchical Database Model

Data is organized in tree's according to relationships (one to many)

Network Database Model

Data is organized in tree's according to relationships (many to many)

Open System Architecture

Hardware, software, transmission, media, and database industry standards allow different computer vendor systems to communicate to each other

Closed System Architecture

Communication is possible only on one vendor's system


Physical equipment that makes up computers and computer systems

What are the 3 types of computers?

Mainframes, minicomputers, microcomputers


Operating systems software and application software

Local Area Network (LAN)

Multiple devices connected via communications media and located in a small geographical area

Wide Area Network (WAN)

A computer network that connects separate institutions across a large geographical area


Private network that has its servers located inside a firewall

Alphabetic Health Record Identification

A patient's name identifies the patient record

Numeric Identification

A number identifies the patient record

Serial Numbering

A new number is assigned to the patient for each new encounter at the facility

Unit Numbering

The patient retains the same number for every encounter at the facility

Serial-Unit Numbering

A new number is assigned to the patient for each new encounter at the facility, but the former records are brought forward and filed under the new number

Centralized Filing

Records filed in one location

Decentralized Filing

Records filed in multiple locations

Alphabetic Filing

Starts with last names and then includes first name and middle initial

Straight Numeric Filing

Filing charts in sequential order; the records start with the chart with the lowest number value and end with the chart with the highest number value

Terminal Digit Filing

Numeric filing is divided into three parts and is read from right to left instead of left to right

What does AHA recommend for record retention?

Minimum of 10 years

When does AHA recommend record retention for a minor?

10 years past the age of majority


Listing or arrangement of data in a designated order; contains special types of information, and purpose is to assist in location of desired information

Master Patient Index (MPI)

Identifies all patients admitted to a health care facility for treatment, along with their identifying information

Number Index

Chronological list of patient's identification numbers issued to patients

Physician Index

Provides every physician with a list of identifying medical cases

Disease Index

List of diseases and conditions according to the classification system used in the facility

Procedure or Operation Index

List of surgical and procedural codes


Created to monitor various diseases and health problems with different goals and objectives

Admission and Discharge Register -- How long retained and in what order?

Permanent in chronological order

Operating Room Register

Maintained for 10 years; provides statistical data for caseload analysis and administrative reports

Births and Deaths Register

Provide accessible information about births and deaths

Emergency Room Register

Monitors patients who enter the emergency room for services

Cancer or Tumor Registry

System that monitors all types of cancer diagnosed or treated in an institution

Health Care Information Management Systems Society (HIMSS)

Provides leadership in health care for the management of technology management systems

International Federation of Health Record Organizations (IFHRO)

Supports national associations and health record professionals to improve health records

International Medical Informatics Association (IMIA)

Promotes informatics in healthcare and bio-medical research

American Medical Informatics Association (AMIA)

Supports information technology professionals to improve health care

American Association for Medical Transcription (AAMT)

Largest association for medical trasncription

College of Healthcare Information Management Executives (CHIME)

Serves needs of health care chief information officers and advocates for more effective use of information management in health care

Alternate Delivery Systems

Health care provided by methods other than the traditional inpatient care, including home health, ambulatory, hospice, and other types of health care.


The management of, responsibility for, or attention to the safety and well-being of another person or other persons


Individual who is receiving professional services

Hill Burton Act

Legislation enacted in 1946 that provided funding for the construction of hospitals and other health care facilities

Secondary Patient Record

A record used for selected data elements to aid in research conducted by clinical and non-clinical people

American Medical Association (AMA) was established to...?

Assure the quality of American medical education

American Hospital Association (AHA) was established to...?

Promote public welfare by providing better health care in hospitals

What did the Flexner Report of 1910 do?

Identify serious problems and inconsistencies in medical education

American College of Surgeons (ACS) was established to...?

Develop a system of hospital standardization to improve patient care and recognize hospitals that had the highest ideals

What is the Department of Health and Human Services (DHHS) responsible for?

Health issues, including health care and cost, welfare of various populations, occupational safety, and income security plans

What did the Tax Equity and Fiscal Responsibilities Act (TEFRA) do?

Established a mechanism for controlling the cost of the Medicare program and set limits on reimbursement and required the development of the prospective payment system

What did the Consolidated Omnibus Budget Reconciliation Act (COBRA) establish?

Anti-dumping statue, established criteria for the transfer and discharge of Medicare and Medicaid patients

What did the Patient Self-Determination Act of 1990 establish?

Gave patients the right to set advance directives

Hierarchical Organizational Chart

Individuals at the top have authority and it passes downward through a chain of command

Vertical Organizational Chart

Governing Board has ultimate authority, followed by the CEO, Medical Staff, Department Directors, Supervisors, and Numerous Subordinates

Matrix Organizational Chart

Supports general managers who focus on managing people and processes as opposed to strategy and structure, horizontal scheme embraces individual capabilities, employees may have two or more supervisors

Product Line Management

Hospitals organized around product line categories (obstetrics, rehabilitation, cardiology)

Health Maintenance Organizations (HMO's)

Managed health care that integrates health care delivery with insurance for healthcare

Nursing Long-Term Care

Nursing care and related services for residents who need medical, nursing, or rehabilitative care provided on a 24 hour basis


Supervision, room, and board provided for those unable to live independently

Mobile Diagnostic Services

Health care services are transported to the patients, especially diagnostic procedures

Fee for Service

Third party payers and/ or patients issue payments to health care providers based on charges assigned to each service performed for each patient

Traditional Fee-For-Service

Third party payers and/ or patients pay health care providers after services have been rendered

Managed Fee-For-Service

Costs are controlled by the managed-care plan's management of members' uses of services; providers are reimbursed by fee schedules

Episode of Care

Health care plan compensates providers with a lump-sum payment to compensate them for all services delivered to a patient for a specific illness and over a specific period of time

Resource-Based Relative Value Scale (RBRVS)

for reimbursement of physician services of beneficiaries covered under Medicare Part B

Clinical Practice Guidelines

Systematically developed statements used to assist provider and patient decisions about appropriate health care for specific clinical circumstances

Clinical Protocols

Treatment recommendations often based on guidelines, step-by-step description of an accepted procedure

Critical Paths

Display goals for patients and provide the corresponding ideal sequence and timing of staff actions to achieve those goals with optimal efficiency

Clinical Pathways

Structured plans of care

Care Maps

Multi-disciplinary standards that outline the processes of care and expected outcomes within predetermined time frames

Private Law (Civil Law)

Recognition and enforcement of the rights and duties of private individuals and organizations


An injury or wrong committed against an individual or his property. One party asserts wrongful conduct on part of the other and seeks compensation for harm suffered


Legally enforceable agreements between two or more individuals

Public Law

Deals with relationships between private parties and the government (criminal law and government regulations)

Criminal Law

Prohibits conduct considered injurious to society as a whole and provides for punishment of those found to have engaged in such conduct

What is the difference between a CRIME and a TORT

A crime is an offense against a person or the public at large. A tort is a civil wrong against an individual


Statutory law written or enacted by bodies such as the U.S. Congress and state and local legislatures

Common Law

Consists of principles that have evolved over time from court decisions resolving controversies

How long does AHIMA recommend keeping an adult patient health record?

10 years after most recent encounter

How long does AHIMA recommend keeping a minor patient health record?

From the age of majority (usually 18) plus a statute of limitation governing medical malpractice lawsuits

Who owns the physical health record?

The healthcare provider, physician, or hospital that maintains it

Who owns the information within the health record?

The patient


The right of an individual to be left alone

What are the three elements of privileged communication?

1. Relationship between patient and provider
2. Information must have been acquired through such a relationship
3. Information must have some connection with the provider's task of treating the patient

Durable Power of Attorney

Legal document in which patients name someone close to them to make decisions about their health care in the event they become incapacitated


Court order requiring someone to appear in court to give testimony

What can happen if you disregard a subpoena?

You can be held in contempt of court

Subpoena Duces Tecum

A written order commanding a person to appear, give testimony, and bring all documents(records) described in the subpoena to court

Subpoena Ad Testificandum

Court order that requires a person to appear in court to testify

Drug Abuse and Treatment Act (1972)

Requires drug and alcohol abuse patient records to be kept confidential and not subject to disclosure except as provided by law

Heath Care Quality Improvement Act (1986)

Established the NPDB

Patient Self Determination Act (1990)

Requires that all health care facilities notify patients age 18 and over that they have the right to have an advance directive placed in their health record

Privacy Act (1974)

Gives individuals some control over the information collected about them by the federal government

Omnibus Budget Reconciliation Act (1987)

Created the Nursing Home Reform Act, which ensures residents of nursing homes receive quality care, requires provision of certain services, and establishes a residents' bill of rights

Tax Equity and Fiscal Responsibility Act (1936) TEFRA

Introduced the Peer Review Organization (PRO) program as a component of Medicare law to ensure the quality of care rendered to patients

Uniform Business Records as Evidence Act (1936)

Stipulates that records can be admitted as evidence in a court of law if they were kept in the ordinary course of business.

Uniform Healthcare Information Act (1985)

Serves as a model for state adoption and provides rules about health information management. As of 1996, only Montana and Washington had enacted this legislation

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