65 terms

Health Info Tech Final

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
Title 19 is a federal and state assistance program that pays for health care services for people who cannot afford them; people on Medicare with low income, limited resources for medical costs
Conditions of Participation (CoP)
Regulations developed by the CMS that describe what a health care organization must do in order to be reimbursed from or participate in specific programs
cancer registrars
Also known as tumor registrars, they collect cancer data from a variety of sources and report cancer statistics to government and health care agencies. The primary responsibility is to ensure the timely, accurate, and complete collection and maintenance of cancer data.
coding specialist
Are responsible for ensuring that all diagnoses, services, and procedures documented in patient records are coded accurately for reimbursement, research, and statistical purposes through the use of coding (assignment of numbers to diagnoses, services, and procedures based on patient record documentation. ) must have working knowledge of ICD and CPT codes
The role of a Risk manager
gathers information, recommends settlements concerning professional and liability incidents, claims, lawsuits investigate and analyze actual and potential risks to the facility review and investigate incident reports and recommends corrective actions
Risk Manager
Investigates incident reports to recommend appropriate corrective action.
Diagnosis-related groups (DRGs)
a system of analyzing conditions and treatments for similar groups of patients used to establish Medicare fees for hospital inpatient services; patients are classified by their principal diagnosis, surgical procedure, age, and other factors.
Length of Stay (LOS)
the number of calendar days a patient was an inpatient
palliative care (comfort management)
What is the goal of hospice care
Federal Certification
Measures ability of health care facilities to deliver care that is safe and adequate, in accordance with federal law and regulation
documentation of patient care
What is the goal of both manual and electronic patient records
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
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.
patient educational plans
Plans to educate the patient about conditions for which the patient is being treated. It is part of the initial plan of the Problem Oriented Record (POR)
Problem Oriented Record (POR)
This type of record includes the data base, the problem list, the initial plan of care, and progress notes that are used by all disciplines
when allowed by state and federal law
When can rubber stamp signatures be accepted by a facility
primary source
documents of patient care provided by health care professionals
secondary source
data extracted from primary sources of patient information
primary source
original patient record, x-rays, scans, and EKG's are all examples of __________ __________
secondary source
indexes, registers, committee minutes, and incident reports are all examples of __________ _________
subjective, objective, assessment, plan
SOAP what does this abbreviation mean
the patient's statement on how she feels and symptoms
What is included in the subjective portion of a SOAP format
Flag & Tag
What is the best way to mark authentication deficiencies in the patient record?
This is a standards development organization that develops EHR standards under the direction of the HHS. (abbreviation)
Health Level Seven
HL7 stands for___________
discharge summary
a ___________ _____________ is required for inpatient hospitalizations greater than 48 hours for uncomplicated cases
pre-existing conditions combined with principal diagnosis will cause an increase in the patient's length of stay by at least one day
Patient is admitted for acute asthmatic bronchitis and also treated for uncontrolled hypertension during the admission. The hypertension is a __________.
centralized filing system
filing system organizes patient records in once central location under the control of the facilities HIM dept.
terminal digit filing system
reversed numeric filing system (three/two/one)
terminal digit filing system
Advantages of the ______ _____ _____ _____ : • high degree of record security
• files expand evenly
• more than one file clerk can easily work based on assigned sections
• simplified planning for filing equipment
• Large gaps in files will not occur as files will be shifted periodically
• Misfiles will be reduced
• Transposition of digits occurs less frequently
• Inactive files can be easily retrieved as new records are added to each section
terminal digit filing system
Disadvantages of the _____ _____ _____ _____:
• Training time for staff is lengthy
• Initially more space and equipment will be needed to organize the filing area.
When a record is removed from the filing system, an __________ is left in its place.
loose filing
Individual reports that must be filed IMMEDIATELY in the patient record after discharge from the facility.
Color-coding filing
assignment of color to primary patient numbers or letters used for filing patient records
and reduce misfiles
Open shelf filing
6-8 shelf unit that resembles a bookshelf, provides twice as much filing space as a standard drawer file cabinet, and requires less then 10 percent additional floor space.
Movable or compressable files
What type of filing units are mounted on tracks?
How to calculate the amount of shelving units needed for record filing
Current inches + Needed inches = Linear Filing Inches
Linear Filing Inches / (#Shelves * Length per shelf) = Number of Filing Systems Needed.
maintained as a "formal or official recording of items, names, or actions." In health care, a record of admission, discharges, births, deaths, operations and other events. They are organized in chronological order, contain patient data, and are used for reference or control purposes.
Master Patient Index
links a person's medical record number with common identification data elements, the key to locating records in HIT file system, In physician offices that do not assign medical record numbers, a ______ is not necessary.
National Center for Health Statistics (NCHS)
federal agency responsible for maintaining official vital statistics
Medical Information Bureau (MIB)
clearinghouse of medical and avocation information about people who pay for insurance.
contains information as an alert for underwriters to review the background of applicants more closely.
goal is to protect insurers, policyholders, and applicants from insurance fraud.
Data Mining
technique using software to search for patterns and trends to produce data content relationships
are wrongful acts for which a civil suit can be brought. Civil suits deal with the legal rights and relationships of PRIVATE INDIVIDUALS. (not gov't, not criminal)
Medical Nomenclature
a vocabulary of clinical and medical terms
used to collect information about diseases and injuries and to classify diagnoses and procedures.
SND - Standardized Nomenclature of Disease
Initiated standardization of anatomical terms used in medicine
*Developed in 1929 by the NY Academy of Medicine
*First Medical nomenclature to be universally accepted in the U.S.
*Introduced the concept of multi-axial coding:
Topology (anatomy)
Etiology (cause of disease)
NOTE: It is a nomenclature and a classification system
standard claim form submitted by hospital, skilled nursing facilities and other institutional-based providers to obtain reimbursement for healthcare services provided to patients
London Bills of Mortality
developed during late sixteenth century.
first classification system.
bills collected and collated by parish clerks (no medical training).
_____(abbreviation) is published by the Psychiatric Association as a standard classification of mental disorders used by mental health professionals in the U.S. It was derived from ICD-9-CM and has three major components: 1. Diagnostic Classifications
2. Diagnostic Criteria Sets
3. Descriptive text
Diagnostic and Statistical Manuals of Mental Disorders
Diagnostic and Statistical Manuals of Mental Disorders
DSM categories
Axis 1 - mental disorders or illnesses
Axis 2 - personality disorders or traits
Axis 3 - general medical illnesses
Axis 4 - life events or problems
Axis 5 - Global Assessment of functioning (GAF)
DSM components
diagnostic classification, diagnostic criteria sets, descriptive text
Subpoena duces tecum
court order demanding an individual to appear in court with documents (medical records)
National Practitioner Data Bank (NPDB)
contains information about practitioners who engage in unprofessional behavior.
restricts the ability of incompetent physicians, dentists, and other healthcare professionals to move out of state without disclosing malpractice incidents or exclusions from Medicare/Medicaid.
the individual who initiates a civil complaint
(Law) a rule of conduct passed by a legislative body that is enforced by the government and results in penalties when violated
What is the best method of communication for members of the health care team caring for a hospital inpatient?
Average Length of Stay
LOS/Discharges + Deaths
What must be obtained for the release of information on a minor child, alcohol and drugs, HIV related information?
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
Straight Numeric Filing
• Staff can be trained quickly
• Record security
• Easy Retrieval
• files expand easily by adding to the end
• Transposition of numbers leading to misfiles
• Misfiles leading to error
• Workflow problems
• Restricted workspace