29 terms

Intro to Health Information Management

Joint Commission
This organization was created as an independent, not for profit organization whose primary purpose was to provide voluntary accreditation for hospitals/health organizations.
independent, not for profit, voluntary, accreditation
The Joint Commission was created as an _____________, _____________ organization whose primary purpose was to provide _________________ _______________ for hospitals/health organizations
Blue Cross
This plan was established in 1929 at Baylor University in Dallas, Texas for school teachers for $6 a year.
1929 , Baylor, Dallas, school teachers, 6, year
Blue Cross plan was established in ___________, at ______________ University in ____________,Texas for _____________ _____________ for $______ a ______.
Governing Board
The __________ ___________serves without pay and is made up of professionals from the business community.
Title 19 is a federal and state assistance program that pays for health care services for people who cannot afford them
Risk Manager
Investigates incident reports to recommend appropriate corrective action.
This is supported by local, state, federal government and taxes, excess income is reinvested in the facility and categorized as government or voluntary.
ambulatory surgery patients
undergo certain procedures that can be performed on an outpatient basis, with the patient treated and released the same day.
Federal Certification
Measures ability of health care facilities to deliver care that is safe and adequate, in accordance with federal law and regulation
Exclusive Provider Organization
managed care plan that provides benefits to subscribers if they receive services from network providers.
Military Health System
The organization that administers health care for active members of the uniformed services {and their dependents}
Qualitative Analysis
Review of the medical record to ensure that standards are met and to determine the accuracy of documentation.
Source Oriented Record
This type of record is arranged according to point of origin Sections include: Nursing notes, Physician Orders, Labs, in reverse chronological order.
Preadmission Testing
PAT stands for
Preadmission Testing
consists of routine laboratory, EKG's and x-ray tests performed on an outpatient basis before a scheduled inpatient admission.
This ordered by the patient's physician to provide timely medical data, to facilitate treatment and reduces inpatients lengths of stay. (ABBREVIATION)
manual medical records
These are the disadvantages or what type of records: record retrieval is not easily customized, hand written information can be illegible, difficult to abstract information, undocumented services are not usually discovered until discharge analysis of record occurs
personal health record
this is an electronic or paper medical record maintained and updated by an individual for his or her own personal use.
The smallest piece of data
tests, images, reporting, administrative
The following 4 things are included in the radiological application within and EHR 1. Ordering of __________ 2. Creation of radiological ___________3. _____________of test results 4. Various _____________________functions.
American Recovery Reinvestment Act
2009 Act that authorized $1.5 Billion for grants for construction, renovation and equipment and for the acquisition of health information technology system.
Administrative Application
What application has 1. Patient Scheduling 2. Admission/registration (insurance, demographics gathering) 3. business/financial functions 4. managerial applications
automated medical records
These are the disadvantages or what type of records: Increased Startup cost, Selection and development of system is time-consuming, staff training is time consuming and expensive, technical staff need to maintain system, user resistance may occur.
Health Level Seven
HL7 stands for___________
This is a standards development organization that develops EHR standards under the direction of the HHS. (abbreviation)
a collection of records is called a ___________
Flag or tag
What is the best way to mark authentication deficiencies in the patient record?
statistical reporting, administrative decision making and quality management purposes
What is the purpose of abstracting patient cases?