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Combo with Essentials of HIM: Ch1 - Health Care Delivery Systems and 1 other

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Imhotep
World's first known physician
Hippocrates
Father of medicine
Hippocratic Oath
Adopted as an expression of early medical ethics
Leeuwenhoek
First to use a microscope to examine microbes
Pasteur and Koch
Established the theory of disease
Pasteur
Proved that microbes are living organisms and that killing microbes stops the spread of disease
Lister
Starting using disinfectant to sterilize surgical wounds and invented aseptic surgery
Roentgen
Discovered x-rays
Curie
Discovered radium and provided a weapon for cancer
Ehrlich
Introduced chemotherapy
Fleming
Discovered Penicillium
Florey
Isolated penicillin from the mold.
1981
Year HIV and AIDS were identified
Pennsylvania Hospital
Benjamin Franklin founded this first United States hospital in 1751
1847
The American Medical Association was founded in this year.
American Medical Association
AMA stands for __________.
American Osteopathic Association
AOA stands for _________.
American College of Surgeons
ACS stands for _________.
American College of Surgeons
This organization was founded in 1913 to improve the quality of care for surgical patients by establishing standards for surgical education and practice.
1946
The Centers for Disease Control was established in this year
Centers for Disease Control
CDC stands for __________.
Joint Commission on Accreditation of Hospitals
This independent, non-profit organization was created in 1951 to provide voluntary accreditation
18
Medicare is title _____ of the Social Security Amendments of 1965.
19
Medicaid is title ____ of the Social Security Amendments of 1965.
Health Care Financing Administration
The Centers for Medicare & Medicaid Services used to be called the ___________.
Health Care Financing Administration
HCFA stands for _______.
Centers for Medicare & Medicaid Services
CMS stands for _______.
Tax Equity and Fiscal Responsibility Act of 1982
This act established the first Medicare prospective payment system which was implemented in 1983. It allowed the implementation of Diagnosis Related Groups.
Tax Equity and Fiscal Responsibility Act
TEFRA stands for _______.
COBRA
Established in 1985, this allowed former employees, retirees, spouses, domestic partners, and eligible dependent children who lose coverage the right to temporary continuation of health coverage at group rates.
Consolidated Omnibus Budget Reconciliation Act
COBRA stands for ________.
Emergency Medical Treatment and Labor Act
Established in 1985, this act addressed the problem of hospitals' failure to screen, treat, or appropriately transfer patients by establishing criteria for the discharge and transfer of Medicare & Medicaid patients.
Emergency Medical Treatment and Labor Act
Also known as the antidumping statute
Emergency Medical Treatment and Labor Act
EMTALA stands for ________.
Patient Self-Determination Act
Established in 1990, this act required consumers to be provided with informed consent, information about their right to make advanced health care decisions (advanced directives), and information about state laws that impact their legal choices in health care decisions.
advanced directives
Do Not Resusciate Order, Durable Power of Attorney for Health Care, Health Care Proxy, Living Will, and Organ/Tissue Donation are examples of _________.
Health Insurance Portability and Accountability Act
Established in 1996, this act mandates administrative simplification regulations that govern privacy, security, and electronic transactions standards for health care information.
Health Insurance Portability and Accountability Act
HIPAA stands for __________.
2001
Health Care Financing Administration changed their name to the Centers for Medicare & Medicaid services in what year?
Medicare Prescription Drug Improvement and Modernization Act
Established in 2003, this act restructured medicare in order to provide recipients with prescription drug savings and additional health care plan choices.
Medicare Prescription Drug Improvement and Modernization Act
MMA stands for _________.
American Recovery and Reinvestment Act
In 2009, this act authorized an expenditure of $1.5 billion for grants for the acquisition of health information technology systems.
continuum of care
A complete range of programs and services
primary care
Services that include preventive and acute care; the point of first contact.
primary care
Services typically provided by a general practitioner or other health professional who has first contact with a patient seeking treatment.
secondary care
Services provided by a medical specialist or hospital staff members to a patient whose primary care was provided first by a general practitioner.
tertiary care
Services provided by a specialized hospital equipped with diagnostic and treatment facilities not generally available at hospitals.
tertiary care
Hospitals that provide burn center treatment, neonatology, neurosurgery, and pediatric surgery provide ___________.
quaternary care
Advanced services provided by tertiary care centers that are highly specialized and not widely used.
for-profit
Privately owned hospitals; excess income is distributed to shareholders and owners.
not-for-profit
Hospitals that reinvested extra income back into the facility.
government, voluntary
Two types of not-for-profit hospitals are _________.
government supported
Hospitals that are supported by local, regional, or federal taxes.
25
Government supported hospitals make up _______ percent of all health care facilities.
government supported
A VA hospital is an example of a __________ facility.
proprietary
Hospitals owned by corporations or private foundations.
15
Proprietary hospitals make up _____ percent of all health care facilities.
voluntary
Not-for-profit hospitals operated by religious or other not-for-profit groups.
60
Voluntary hospitals make up _____ percent of all health care facilities.
teaching
Hospitals affiliated with a medical school.
Intern
An individual in their first year of graduate medical education.
resident
A physician who has completed an internship and is engaged in a program of training designed to increase his or her knowledge of the clinical discipline.
chief resident
Physician in his or her final year of residency.
Domagk
Discovered the ability of sulfa drugs to cure infections
1955
Year the Salk polio vaccine was licensed
1765
Year the first medical school was founded
University of Pennsylvania
The first medical school was founded at ____________.
1913
Year American College of Surgeons was founded.
1897
Year American Osteopathic Association was founded.
1935
Year Congress passed the Social Security Act.
1965
Year Medicare and Medicaid was established
1951
Year the Joint Commission was established.
governing board; administration; medical staff; departments, services, and committees; contracted services
What is the top-down organizational structure for a health care facility?
governing board
Group that serves without pay and is represented by professionals from the business community.
governing board
This group is responsible for hospital organization, management, control and operations, and for appointing medical staff.
governing board
This group is responsible for the overall health of the organization.
hospital administration
Group that serves as a liaison between the medical staff and the governing board.
hospital administration
This group is responsible for developing a strategic plan for supporting the mission and goals of the organization.
CFO
This person reports to CEO and is responsible accounting, billing, and payroll
CIO
This person reports to the CEO and is responsible for information resource management.
COO
This person reports to CEO and is responsible for ancillary services.
medical staff
Consists of licensed physicians and other licensed providers as permitted by law who are granted clinical privileges.
governing board
The medical staff is approved by the ___________.
clinical departments, medical specialty, chairperson, medical staff committees, hospital committees
The medical staff is organized into ________ by _________, with a _________ appointed to each department, and members to serve on ____________ and ___________.
medical staff credentials committee
This group reviews and verifies medical staff applications and submits recommendations to the executive committee.
department chairperson
Once the credentials committee reviews a medical staff application, the application then goes to this person.
executive committee
This group reviews medical staff applications and recommendations, votes, and makes recommendations to Medical Staff.
active
Medical staff involved in the delivery of medical services and administrative functions.
associate
Medical staff under consideration for active status
consulting
Highly qualified medical staff that provide expertise in an specific area
courtesy
Medical staff who occasionally admits a patient to the hospital
honorary
Former medical staff held in high regard and honored with emerti status
bylaws
The rules and regulations of the health care organization as guided by federal and state regulations and accreditation standards.
bylaws
These are created and voted on by the medical staff; they delineate medical staff responsibilities.
departments
Clinical laboratory, HIM, radiology, medical staff are examples of hospital ____________.
committees
Hospital ______________ are multidisciplinary and comprised of representatives from various departments.
agenda
A listing of all items of business to be discussed
review minutes, old business, member reports, new business, other business, next meeting, adjournments
List the seven items on a standard agenda.
minutes
Concise, accurate records of actions taken and decisions made during the meeting.
date, place, time of meeting; members present; members absent; guests present; items discussed; actions taken; adjournment time; date, place, time of next meeting; secretary's name and signature
What 9 things should be in the meeting minutes?
health information
Department responsible for allowing appropriate access to patient information in support of clinical practice, health services, and medical research while maintaining confidentiality of patient and provider data.
RHIA, RHIT
Health information administrative functions are directed by __________ and _________.
HIM administrators
These individuals develop, monitor, and improve HIM systems, ensure continuous quality operation, participate in committees, and establish department policies and procedures.
cancer registrars
These individuals use computerized registry software to conduct lifetime follow-up on cancer patients, electronically transmit data to state and national agencies, and generate reports and information for requesting entities.
cancer registrars
These individuals coordinate the national survey process through the ACS commission on cancer and arrange monthly or bi-monthly cancer committee meetings.
coding
Involves assigning numeric and alphanumeric codes to diagnoses, procedures, and services.
RHIA, RHIT, CCS
Coding is performed by _______, __________, or _______.
CPT
Coding method used only for ambulatory/outpatient procedures and services.
current procedural terminology
CPT stands for _________.
AMA
CPT is put out by the _________.
ICD-9-CM
Used to collect information about diseases and injuries and to classify diagnosis and procedures.
HCPCS Level II
Codes developed by CMS and used to classify report procedures and services.
health care procedure coding system
HCPCS stands for __________
image processing
HIM department responsible for converting paper to electronic health records via digital media, scanned images, and voice recognition.
need-to-know
Only employees who have been granted ________ status are allowed access to EHR.
locked
Records that are in litigation or behavioral health records are usually _________.
incomplete record processing
This included the assembly and analysis of discharged patient records for deficiencies.
universal chart order
All records are organized in the same order as when the patient was on the nursing floor.
logged into the tracking system, physician is notified
Once the record is analyzed for deficiencies, it is __________, and then __________.
medical transcription
Involves the accurate and timely transcription of dictated reports
record circulation
Includes the retrieval of patient records for the purpose of inpatient readmission, outpatient clinic visits, authorized quality management studies, and education and research.
cancer registry, coding, document conversion, medical transcription, release of information, trauma registry
Provide six examples of HIM contracted services.
licensure
State laws require a health care facility to obtain this before providing services to patients.
regulation
An interpretation of a law that is written by the responsible regulatory agency.
Code of Federal Regulations
The codification of the general and permanent rules published in the Federal Register.
accreditation
The voluntary process that a health care facility or organization undergoes to demonstrate it has met standards beyond those required by law.
standards
Measurements of a health care organization's level of performance in specific areas - more rigorous than regulations
survey
Process conducted both off-site and on-site to determine whether the facility complies with standards.
deemed status
Organization has met the conditions of participation which allows them to accept reimbursement for CMS
ORYX initiative
Integrates outcomes and other performance measurement data into the accreditation process for quality improvement purposes.
Shared Visions - New Pathways Initiative
Changed the scoring and accreditation process, focusing on whether organizations are making improvements system-wide.
Periodic performance review
Developed by the joint commission, this is a continuous survey process that helps organizations meet the continuous demand for accountability and is used for self-evaluation.
National Patient Safety Goals
Developed by the JC, these help organizations focus on providing high quality patient care.
privacy, security, electronic transactions standards
HIPAA sets regulations for the _______, _______, and __________ for health care information.
predetermined rate, discharge diagnosis
Diagnosis related groups required acute care hospitals to be reimbursed at a ______ according to ________.
hippocrates
First to consider medicine both a science and art, separate from practice of religion.
ACS
The _______ developed the minimum standard for hospitals.
voluntary accreditation
The primary purpose of the Joint Commission is to provide ________.
professionals from the community
The membership of the governing board is represented by _________.
credentials
This committee consists of medical staff who review and verfy medical staff applications.
utilization management
A person from this department works with case managers of insurance companies to determine the appropriateness of admissions.
incomplete record processing
The assemby and analysis of discharged patient records.
procedures and services
The CPT coding book is published annually to assign what type of codes.
AMA
Who publishes the CPT coding book?
risk management
A hospital committee that is responsible for analyzing trends of accidents and establishing priorities for dealing with high-risk areas is ___.
National Committee for Quality Assurance
Private non-profit organization established to assess and report on the quality of managed care plands is called the _______.
better, higher quality
Health care consumers are _____ educated and demand _______ health care.
modern
The implementation of standards for sanitation, ventilation, hygiene, and nutrition occurred during ______ medicine.
monks and nuns
In the Middle Ages, the care of patients was based on charity and was often managed by _______.
written authorization, court order
Health care information can be released only with patient's _____ or by a ______.
electronic health record
Automated, accessible record containing multimedia data.
electronic signature
Encompasses all technology options available used to authenticate a document.
disaster control
Committee responsible for establishing a disaster plan.
health information
Committee responsible for ongoing review of patient records for timely completion and quality of documentation.
quality management
Committee concerned with the quality of care provided to patient.
risk management
Committee responsible for coordinating and monitoring activities, analyzing trends of incidents, and establishing priorities for dealing with potentially dangerous areas.
utilization management
Committee concerned with appropriate use of resources for providing patient care.
ethics
Committee that meets as needed in order to discuss ethical problems.
executive
Committee that acts on reports and recommendations from medical staff committees.
joint conference
Committee that serves as a liaison betwee governing body and administration.
abstracting
The purpose of ______ is to generate statistical reports, and disease/procedure indexes which are used for administrative decision-making and quality-management purposes.
standard, medical education
The original purpose of the AMA was to elevate the ______ of _______.
art, science, betterment, public health
The current purpose of the AMA is to promote the _____ and _____ of medicine and the ______ of ______.
American hospital association
AHA
american hospital association
National organization that represents and serves all types of hospitals, health care networks, and their patients and communities
peer review organizations
What group replaced PSROs in 1982?
peer review organizations
Implemented in 1982, these organizations monitored utilization and quality control.
quality improvement organizations
In 2002, PROs were replaced with _____?
quality improvement organziations
These organizations, established in 2002, perform quality control and utilization review of health care furnished to Medicare beneficiaries.
professional standards review organziations
Established in 1972 by the Social Security Amendments, these peer review organizations monitor appropriateness, quality, and outcome of services provided to beneificiaries of Medicare, Medicaid, and Maternal and Child Health Programs.
Social security
When it was originally established, what act included unemployment insurance, old-age assistance, aid to dependent children, and grants to states to provide various forms of medical care?
unemployment insurance, old age assistance, dependent children, medical care
When it was originally established, social security included: _______, _______, aid to ______, and grants to states to provide ______.
CEO
This person oversees, the CFO, CIO, and COO.
house officers
Physicians whose only job is to work at the facility treating patients.
governing board
This group grants medical staff clinical privileges.
The Joint Commission
What organization was established in 1951 to develop professionally based standards to evaluate compliance of health care organizations?
medicare
Comprehensive health care available to people 65 years of age or older, certain younger people with disabilities, and people with end-stage renal disease.
medicaid
A joint federal and state program that helps with medical costs for people with low incomes and limited resources.
reverse chronological order
Inpatient reports are filed in _______ within each section of the record.
chronological order
Discharged patient reports are filed in _____ within each section of the record.
hippocrates
Which physician was the first to consider medicine a science?
component state organizations
The AHIMA House of Delegates are composed of delegates from _____.
ANSI
American National Standards Institute
ASTM
American Society for Testing and Materials
DEEDS
Data Elements for Emergency Department Systems
HHS
Department of Health and Human Services
DICOM
Digital Imaging and Communication in Medicine
EDI
Electronic Data Interchange
HEDIS
Health Plan Employer Data and Information Set
IEEE
Institute of Electrical and Electronics Engineers
MDS 2.0
Minimum Data Set for Long-term Care Version 2.0
NCHS
National Center for Health Statistics
NCVHS
National Committee on Vital and Health Statistics
NHIN
Nationwide Health Information Network
ONC
Office of the National Coordinator of Health Information Technology
OASIS-C
Outcomes and Assessment Information Set
PPS
Prospective Payment System
SDOs
Standards Development Organizations
UACDS
Uniform Ambulatory Care Data Set
UHDDS
Uniform Hospital Discharge Data Set
American National Standards Institute (ANSI)
The organization that accredits all U.S. standards development organizations to ensure that they are following due process in promulgating standards
American Society for Testing and Materials (ASTM)
A national organization whose purpose is to establish standards on materials, products, systems, and services
Core data elements/core content
A small set of data elements with standardized definitions often considered to be the core of data collection efforts
Core measure
Standardized performance measures developed to improve the safety and quality of healthcare (for example, core measures are used in the Joint Commission on Accreditation's ORYX initiative)
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
Data element
An individual fact or measurement that is the smallest unique subset of a database
Data Elements for Emergency Department Systems (DEEDS)
A data set designed to support the uniform collection of information in hospital-based emergency departments
Data set
A list of recommended data elements with uniform definitions that are relevant for a particular use.
Data standard
are the agreed upon specifications for the values acceptable for specific data fields
Department of Health and Human Services (HHS)
The cabinet-level federal agency that oversees all of the health - and human-services-related activities of federal government and administers federal regulations.
Digital Imaging and Communication in Medicine (DICOM)
A standard that promotes a digital image communications format and picture archive and communications systems for use with digital images
Electronic data interchange (EDI)
A standard transmission format using strings of data for business information communicated among the computer systems of independent organizations
Health Plan Employer Data and Information Set (HEDIS)
A set of performance measures developed by the National Commission for Quality Assurance that are designed to provide purchasers and consumers of healthcare with the information they need to compare the performance of managed care plans
Hospital discharge abstract system
A group of databases compiled from aggregate data on all patients discharged from a hospital
Inpatient
A patient who is provided with room, board, and continuous general nursing services in an area of an acute care facility where patients generally stay at least overnight
Institute of Electrical and Electronics Engineers (IEEE)
A national organization that develops standards for hospital system interface transactions, including links between critical care bedside instruments and clinical information systems
Medicare prospective payment system
When the Prospective Payment Act was enacted in 1983, the UHDDS definitions that had been in place since 1974 were incorporated into the rules and regulations of using diagnosis-related groups (DRGs) as a classification tool; prospective payment is a type of reimbursement system that is based on preset payment levels rather than actual charges billed after the service has been provided
Minimum Data Set for Long-Term Care Version 2.0 (MDS 2.0)
A federally mandated standard assessment form that Medicare- and Medicaid- certified nursing facilities must use to collect demographic and clinical data on nursing home residents
National Center for Health Statistics (NCHS)
The federal agency responsible for collecting and disseminating information on health services utilization and the health status of the population in the United States
National Committee on Vital and Health Statistics (NCVHS)
A public policy advisory board that recommends policy to the National Center for Health Statistics and other health-related federal programs
Nationwide Health Information Network (NHIN)
System that links various healthcare information systems together, allowing patients, physicians, healthcare institutions, and other entities nationwide to share clinical information privately and securely
Office of the National Coordinator of Health Information Technology (ONC)
Office that provides leadership for the development and implementation of an interoperable health information technology infrastructure nationwide to improve healthcare quality and delivery
ORYX Initiative
The Joint Commission on Accreditation of Healthcare Organizations' initiative that supports the integration of outcomes data and other performance measurement data into the accreditation process
Outcomes and Assessment Information Set (OASIS-C)
A standard core assessment data tool developed to measure the outcomes of young adult patients receiving home health services under the Medicare and Medicaid programs
Outpatient
A patient who receives ambulatory care services in a hospital-based clinic or department
Prospective payment system (PPS)
A type of reimbursement system that is based on preset payment levels rather than actual charges billed after the service has been provided; specifically, one of several Medicare reimbursement systems based on predetermined payment rates or periods and linked to the anticipated intensity of services delivered as well as the beneficiary's condition
Standards development organizations (SDOs)
Private or government agencies involved in the development of healthcare informatics standards at a national or international level
Transaction standards
Standards that support the uniform format and sequence of data during transmission from one healthcare entity to another
Uniform Ambulatory Care Data Set ( UACDS)
A data set developed by the National Committee on Vital and Health Statistics consisting of a minimum set of patient/client-specific data elements to be collected in ambulatory care settings
Uniform Hospital Discharge Data Set (UHDDS)
A core set of data elements adopted by the U.S. Department of Health, Education, and Welfare in 1974 that are collected by hospitals on all discharges and all discharge abstract systems
chart locator system
a system for locating records within a facility
computer based patient record
compilation of patient helath information in a relational or other computer database
file folder
the physical container used to store the health record in a paper based system
index
a system to identify or name a file or other item so that it can be located
master patient index (MPI)
a system containing patient & encounter information, often used to correlate the patient to the file identification
microfiche
alternative storage method for paper records on plastic sheets
microfilm
alternative storage method for paper records on plastic film
optical disk
electronic storage medium; a disk used to store digital data
outguide
a physical file guide used to identify another location of a file in the paper based health record system
record retention schedule
the length of time that a record must be retained
scanner
a machine, like a copier used to turn paper based records into digital images for a computerized health record
serial numbering
a numerical patient record identification system in which the patient is given a new number for each visit & each file folder contains separate visit information
straight numerical filing
filing folders in numerical order
unit numbering
a numerical patient record identification system in which the patient record is filed under the same numer for all visits
1st Hospital in N.A.
Philadelphia Hospital 1752, founded in part by Benjamin Franklin.
1st Hospital in Western Hemisphere
Mexico 1500's
AMA
American Medical Association
established 1846
Wanted to raise the quality of medical care in the US
Flexner Study
Abe Flexner
With a grant from the Carniege Foundation and the ACS, completed a study of med schools in US, reported 1910.
Shut a lot of schools down
Standardized curriculum.
Established you needed a college degree to get into med school.
By 1920 AAMC (Association of American Medical Colleges), most schools met the stanrd.
Flexner introduced the idea that a Physician in med school, should be affiliated with a hospital to get hospital training
Determined min care and documentation standards that you must meed to provide care.
**89 of 692 Hospital surveyed, met these standards.
Medicaid
Funded by the Federal and State government.
State determines eligibility and what's covered.
State is responsible for administering.
Gives health benefits to low-income family's and individuals.
Medicare
Funded and established by the Federal government.
Gives health benefits to people ages 65 and older, including hospital care.
Public Law 89-97: 1965
Title 18 and 19 of Social Security Act
Established Medicare and Medicaid.
Social Security Act 1935
Provides income to people ages 65 and older.
Initially had socialized medicine in the bill but then omitted because of the negative connotation of "socialized" of the time.
Biological Control Act 1902
First federal government intervention in the medical field.
Regulated vaccines and medications.
Hill-Burton (Hospital Survey and Construction Act: 1946)
Enacted after World War 2 in 1946 by Truman.
Provided rennovation and construction grants for new and existing hospitals.
In return, the hospital would have to set aside a portion of their budget each year to provide low-cost or free health care to low-income individuals.
Public Law 92-603: 1972
Utilization Review Mandatory
Ensuring that medical stays were neccessary and not the hospital just trying to make money--Medicare patients.
Utilization Review Act: 1977
Reinforced and mandated stay reviews from Public Law 92-603
Health Planning and Resources Development Act of 1974
Health Systems Agency established
ANA
American Nurses Association
Governs nursing education and practice.
National Institute of Health
Works on new treatments and advancements in care for the health field.
Mental Health Parity Act of 1996
Fed law says insurance companies have to provide equality for mental health benefits as physical benefits.
Peer Review Improvement Act: 1982
Now called Quality Improvement Organization (QIO)
Agencies contracted by Medicare to review quality and appropriateness of care of medicare patients.
Tax Equity and Fiscal Responsibility Act: 1982
TEFRA
Wanted to switch to cost based payment based on patients condition. Perspective payments and now DRG's.
Public Law 98-21: 1983
Implemented perspective payments in hospitals.
HIPAA
1996
Administration Simplification Standards
ARRA developed stricter standards to add to HIPAA
HITECH, is a provision of the act.
Omnibus Budget Reconciliation Act: 1986
Established National Practitioner Databank
Every physician who practices in the US is in it.
Shows any malpractice claims.
Hospitals have to access it before they can allow a DR to practice in their hospital.
Have to check it every 2 years
AHA
American Hospital Association
Established to enhance quality of care in hospitals.
TJC
The Joint Commision 1952
Made up of the ACS, AMA, APA
Accrediting and quality of care.
Omnibus Budget Reconciliation Act: 1989
Established Healthcare licensing agencies.
Classification of Hospitals
5 Factors:
1) # of beds: determines size of the hospital
2)Type of service: cancer, respiratory etc...
3)Types of patient: women's, children etc...
4)For-profit or not-for-profit
5)Type of ownership: Govt, Sectarian, Voluntary, Proprietary
Sectarian
Operated by Religious orders.
Voluntary.
Non-profit
Just meet their needs.
Cant charge more than the costs.
Not-for-profit
Can charge more than actual cost, and the excess goes back into the hospital.
For-profit
Proprietary
Charge more than the actual costs and can take the excess and do what they please, such as; give out dividends to share-holders, bonuses, or back into the hospital.
Govt Operated Hospitals
Funded in part by tax $
Profits go back into state budget
Federal, State and Local.
BOD
Board of Directors in a Hospital.
Trustees, made up of key members from the community.
Governing Board.
Have the TOTAL responsibility for Quality of Care in the hospital.
Delegates medical care to staff but still responsible.
Delegates operational authority to administrative staff. (CEO, CNO)
Credentialing
The process which a hospital disapproves or approves requests to practice at their facility.
Category
codes in the tabular section of CPT are formatted using four classifications: sections, sub sections, subheading, and category. Category is the most definitive classification and aids in selection the applicable code.
Category III codes
Established by AMA as a set of temporary CPT codes for emerging technologies, services, and procedures where data collection is needed to substantiate widespread use or for the Food and Drug administration's approval process.
Centers for Medicare and Medicaid Services (CMS)
agency responsible for administrating the Medicare and Medicaid programs. Developed the CPT codes to establish a more uniform payment schedule for Medicare carriers to use when reimbursing providers. Formerly called the Health care Financing Administration
Chief complaint
the reason why the patient is seeing the physician.
Concurrent care
when a patient receives similar services (e.g., hospital visits) by more than one healthcare provider on the same day.
Consultation
when the primary care provider sends a patient to another provider, usually a specialist, for the purpose of the consulting physician rendering their expert opinion regarding the patient's condition. The primary care provider does not relinquish the care of the patient to the consulting physician
Counseling
a service provided to the patient and their family that involves impressions and recommended diagnostic studies, discussion of diagnostic results, prognosis, risk and benefits of treatment, and instructions.
Critical care
the constant attention (either at bedside or immediately available) by a physician in a medical crisis
Crosswalk
the process of matching one set of data elements or category of codes to their equivalents within a new set of elements or codes
Emergency care
care given in a hospital emergency department
Established patient
a person who has been treated previously by the healthcare provider, regardless of location of service, within 3 years
Evaluation and Management Codes (E&M)
codes found at the beginning of the CPT manual that represent the services provided directly to the patient during an encounter that do not involve an actual procedure
Face to face time
the time that the healthcare provider spends in direct contact with a patient during an office visit, which includes taking a history, performing an examination, and discussing results.
HCFA's Common Procedure Coding System ( HCPCS)
developed by the Health care financing administration to provide a uniform language that accurately describes medical, surgical, and diagnostic services, serving as an effective means for reliable nationwide communication among physicians, insurance carriers, and patients.
HCPCS codes
descriptive terms with letters or numbers or both used to report medical services and procedures for reimbursement. Provides a uniform language to describe medical, surgical, and diagnostic services. HCPCS codes are used to report procedures and services to government and private health insurance programs, and reimbursement is based on the codes reported
Health care financing administration (HCFA)
now known as CMS
History of present illness (HPI)
elements of a physician examination that includes location , quality, severity, duration, timing, contest, modifying factors, and associated signs and symptoms of a patient's current illness or injury.
Indented code
codes that refer back to the common portion of the procedure listed in the preceding entry
Key components
the main elements that establish the level in evaluation and management coding (history, examination, and complexity in medical decision making).
Level I (code)
AMA Physician's CPT codes. Five digit codes, accompanied by descriptive terms. Used for reporting services performed by healthcare professionals Level I codes are developed and updated annually by the AMA
Level II (code )
HCPCS national codes used to report medical services, supplies, drugs, and durable medical equipment not contained in the Level I codes. Codes that begin with a single letter, followed by 4 digits. Level II codes supersede Level I codes for similar encounters. E&M services or other procedures and represented the portion of the procedures involving supplies and materials. Level II codes are developed and updated annually by the CMS and their contractors
Level III (code)
codes and description developed by local Medicare contractors for use by physicians, practitioners, providers and suppliers in completion of claims for payment. Level III codes are now used on a limited basis
Modifier
words that are added to main terms to supply more specific information about the patients clinical picture. Modifiers provide the means by which the reporting healthcare provider can indicate that a service or procedure performed has been altered by some specific circumstance, but has not changes its definition or code
Modifying term
descriptive words indented under the main term that provide further description of a procedure or service. A main term can have up to three modifying terms. The CPT coding, modifying terms often have an effect on the selection of the appropriate procedural code
Neonates
newborns 30 days old or younger
New patient
a person who is new to the practice, regarding of location of services, or one who has not received any medical treatment by the healthcare provider or nay other provider in that same office within 3 years.
Observation
in CPT coding, a classification for a patient who is not sick enough to qualify for acute inpatient status, but requires hospitalization for a brief time
Outpatient
a patient who has not been officially admitted to a hospital, but receives diagnostic test or treatment in that facility or a clinic connected with it.
Past, family, and social history (PFSH)
Part of a physical examination that includes the patients past illnesses, operations, injuries, and treatments, and any diseases or conditions other family members might have, which could be heredity.
Physicians' Current Procedural terminology, Fourth edition (CPT-4)
a manual containing a list of descriptive terms and identifying codes used in reporting medical services and procedure performed and supplies used by physicians and other professionals in the care and treatment of patients
Physicians' Current Procedural terminology, Fifth edition (CPT-5)
an updated version of the CPT-4 manual, which the AMA is in the process of developing that will improve existing CPT features and correct deficiencies. The updated version is structured to respond to challenges presented by emerging user needs and HIPAA
Review of systems (ROS)
in a physical examination, information gathering that involves a series of questions the provider asks the patient to identify what body parts or body systems are involved
Inpatient
a patient who has been formally admitted to a hospital for diagnostic test, medical care and treatment, or surgical procedure, typically staying overnight
Section
one of four classifications in the tabular section (volume I) of the CPT manual. This section is one of the six major areas into which all CPT codes and descriptions are categorized
See
used as a cross reference term in the CPT alphabetic index and directs the coder to an alternate main term
Special report
a report that accompanies the claim to help determine the appropriateness and medical necessity of the services or procedures. It is required by many third party payers when a rarely used, unusual, variable, or new service or procedure is preformed
Stand alone code
a CPT code that contains the full description of the procedure without additional explanation
Subheading
one of four classifications in the tabular section (Volume I) of the CPT manual
Subjective information
biased or personal information. A patient's own words of what is wrong
Subsection
one of four classifications in the tabular section of the CPT manual that further divides sections into smaller units, usually by body systems
Unit/ floor time
time a physician spends on bedside care of the patient and reviewing the health record and writing orders.
Category III Codes
Established by the AMA as a set of temporary CPT codes for emerging technology, services, and procedures.
Centers for Medicare and Medicaid Services (CMS)
Agency responsible for administering the Mediare and Medicaid programs.
Cheif Complaint (CC)
The reason why a patient is seeing the physician.
Consultation
When the PCP sends a patient to another provider, using a specialist, for a second opinion.
Critical Care
The constant attention by a physician in a medical crisis.
Established Patient
A patient who has been treated previously by a healthcare provider regardless of the location, within the past 3 years.
HCFA's Common Procedural Coding System (HCPCS)
Developed by Health Care Financing Administration to provide a uniform language that accuratley descibes medical, surgical, and diagnostic services.
Inpatient
A patient who has been formally admitted to the hospital.
Key Components
The key elements that establish the level of Evaluation and Management coding.
Level I Codes
AMA developed 5 digit CPT codes used for reporting physician services.
Level II Codes
National alphanumeric codes used to report medical services, supplies, drugs and durable medical equipment.
Level III Codes
Codes and descriptors developed by Medicare contractors for use by physicians, practitioner, providers, and suppliers on a local level.
Modifier
Words that are added to main terms to supply more specific information about the patient's clinical picture.
Neonates
Newborns, 30 days old or younger.
Observation
A classification in CPT coding for a patient who is not sick enough to be admitted but requires brief hospitalization.
Outpatient
A patient who has not officially been admitted but receives diagnostic test or treatment in a facility.
Current Procedural Coding 4th Edition (CPT-4)
A manual created by AMA that lists codes for physicians services and procedures.
Review of Systems (ROS)
A series of questions asked by a physician during a an exam, based on body system.
Special Report
A report that accompanies a claim that helps determine medical necessity for services performed.
Stand-Alone Code
A CPT code that contains the full description of the procedure.
RHIO (Regional Health Info organizations)
now called HIE (health info exchange) organizations, created under Bush w/ EHR adoption plan, created through ONC for HIT.
NHIN/NHII
National Health Info Network/National Health Info infrastructure
HIM has been recognized as an allied Health profession since:
1928
The hospital standardization movement was inaugurated by the :
American College of Surgeons
Throughout the years, HIM roles have:
Broadened in scope
The traditional model of HIM practice was:
Department based
The new model of HIM practice is:
Information based
What evolving role oversees the process that begins at the time of documentation through billing?
Revenue cycle management
The organization that accredits HIM programs is:
CAHIIM:
What evolving role assesses quality in health record banking?
Health record reviewer
The primary focus of AHIMA is to:
Foster professional development of its members
Active members of AHIMA include those who:
Are senior members
Which of the following functions as the legislative body of AHIMA?
House of Delegates
Which of the following promotes education and research?
AHIMA foundation
The virtual network used by AHIMA members is:
Communities of Practice
We have 324 Medicare patients last month. This statement represents which of the following:
Data
I am a patient. My medical history including information from myself and my physicians in stored on the Internet. This is an example of which of the following:
PHR: Personal Health Record
Which of the following is an example of a primary purpose of the medical record?
Patient care management
Examples of patient care delivery usage if the medical record include which of the following uses?
Communication of practice guidelines
Critique this statement: The PHR and EHR are synonyms.
This is a false statement as the PHR is controlled by the patient and the EHR is controlled by the care providers
Which of the following users of the health record is an example of an institutional user?
Third-party payer
Which of the following users would utilize aggregate data?
Patient care managers and support staff
I wok for an organization that utilizes health record data to prove or disprove hypotheses related to disease. I must work for what type of organization?
Research
Critique the following statement: A user of health records includes only care providers who document in the health record of refer to it for patient care.
This is a false statement as the information is used for other purposes such as analysis
I work for CMS; how would I use the health record?
Make decisions on healthcare reimbursement
A physician just received notification from an EHR system that a patient's lab test had a dangerously high value. This is an example of what kind of clinical tool?
Clinical decision support
I just told my physician something embarrassing about myself. I told him because I expect him to use the information for my care only. This concept is called:
Confidentiality
Someone suggested that we collect a patient's eye color. This was not implemented. What quality characteristic would be the justification for not collecting this information?
Relevancy
It was suggested that we enter the patient's age manually in all of our information systems. What quality characteristic would be the justification for not doing this, but rather sharing information between the systems?
Consistency
According to the AHIMA sate quality model, what is the term that is used to describe how data is translated into information?
Data analysis
Which two major types of data are contained inn the health record?
Administrative and clinical
Which of the following terms refers to state or county regulation that healthcare facilities must meet to be permitted to provide care?
Licensure
Which of the following would not be found in a medical history?
Vital signs
An attending physician requests the advice of a second physician who than reviews the health record and examines the patient. The second physician records impressions in what type of report?
Consultation
Which specialized type of progress note provides healthcare professionals impressions of patient problems with detailed treatment action steps?
Care plan
Written or spoken permission to proceed with care is classified as:
Expressed consent
Which of the following reports provides information on tissue removed during a procedure?
Pathology report
Sleeping patterns, head and chest measurements, feeding and elimination status, weight, and Apgar scores are recorded in which of the following records?
Newborn
Which of the following is not considered patient demographic information?
Admitting diagnosis
Which of the following administrative documents name s the patient's choice of legal representative for healthcare purposes?
Advance directive
Which type of health record contains information about care provided prior to arrival at a healthcare setting and documentation of care provided o stabilize the patient
Emergency care
patient history questionnaires, problem lists, diagnostic tests results, and immunization records are commonly found in which type of record?
Ambulatory care
The ambulatory surgery record contains information most similar to:
Hospital operative records
Which standardized tool is used to assess Medicare-certified rehabilitation facilities?
Patient assessment instrument PAI
Interdisciplinary care plans are an important part of which type of health record?
Hospice care
Portions of a treatment record may be maintained in a patient's home in which two types of settings?
Home health and end-stage renal disease
A patient's legal status, complaints of others regarding the patient, and reports of restraints or seclusion would be found most frequently in which type of health record?
Rehabilitative care
Paper records may require thinning in which two settings?
Long-term care and correctional services
A growth and development record may be found in what type of record?
Pediatric
The document that indicates current and past medical conditions is :
Problem list
Which of the following is an accrediting organization?
DNV (Det Norske Veritas)
An accrediting organization is awarded deemed status by Medicare. This means that facilities receiving accreditation under its guidelines do not need to:
Undergo Medicare certification surveys
Which group focuses on accreditation of managed care and preferred provider organizations?
National Committee for Quality assurance
Which of the following regulations would most likely contain information on who is authorized to enter documentation in a patient's record?
Facility rules and regulations
Which of the following groups has instituted a health record-prohibited abbreviation list?
Joint Commission on Accreditation of Healthcare Organizations
Which type of health record includes both paper and computerized components?
Hybrid
Which of the following is a disadvantage of an EHR over a paper-based record?
Requires privacy and security measures
In an integrated health record, documentation by health professionals is organized:
Intermixed in date sequence
The patient indicates that her pain is worse. In which part of a SOAP note would this information be recorded?
Subjective
Which of the following electronic record technological capabilities would allow an x-ray to be sent to a physician in another state?
Image processing
HTTP
Hypertext Transfer Protocol, hypertext transfer protocol are the rules computers use to transfer web pages across the Internet
LAN
local area network (1 area); desihned to connect a group of computers in close proxomity to each other such as in an office, school, home, etc
WAN
a computer network that spans a wider area than does a local area network.
MDS
minimum data set; component of the mandated assessment process entitled the Residnet Assessment Instrument (RAI); provides outline of most essential info
MRI
Magnectic Resonance Imaging-a technique that uses magnetic fields and radio waves to produce computer-generated images that distinguish among different types of soft tissue
PACS
Picture Archiving and Communitcations System - computer system that can manage images in an electronic form
PDA
Personal Data Assistant -a wireless microprocessor providing access to the internet, daily planner, address book, etc
PDF
Portable Document Format. A file format developed by Adobe Systems to allow for display and printing of formatted documents across platforms and systems. PDF files can be read on any system equipped with the Acrobat Reader software.
PET
Position Emmission Tomography-using a computerized radiographic technique to examine the metabolic activity in various tissues (especially in the brain)
PoP3
Post Office Protocol version 3- protocol used to transfer mail between a send mail server and microsoft exchange server
RAID
Redundant Array of Independent Disks-a group of two or more integrated disks that acts like a single large hard disk
RIS
radiology information system; a database of images and pt records specific to the imaging dept.
SAN
Storage Area Network- high-speed network with the sole purpose of providing storage to other servers to which it is attached
SSL
Secure Sockets Layer- a protocol used for transmitting sensitive data (credit info) over the internet http://
TCP/IP
Transmission Control Protocol/Internet Protocol, a protocol for communication between individual computers and the Internet
HL7
Health Level 7; standards development organization accredited by the American National Standards Institute that addresses issues at the 7th, or application, level of healthcare system interconnections
HIS
Health Information Sytem- a combination of health statistics from various sources, used to derive information about health status, health status, health care, provision and use of services, and impact on health
HIM
Health Information Management-directing and organizing all activities related to keeping and caring for information concering healthcare provided for the paitent
DICOM
Digital Imaging & Communications in Medicine: Industry standard specifications for inter-communications between medical imaging equipment
COLD
Computer Output to Laser Disk-a method of outputting directly to disk instead of printing them to paper and the scanning them.
CCOW
Clinical Context Object Workgroup-The standard is designed to allow software from different vendors to retain the selected patient and provider when switching among providers.
CAT
Computerized Axial Tomography-uses multiple xrays and a computer to generate images of cross sections of the body
ASCII
abbreviation of American Standard Code for Information Interchange, a standard computer code used to assist the interchange of information among various types of data-processing equipment, The American Standard Code for Information Interchange. It is a mapping that takes common characters in American English and maps them to number so that they can be represented on a computer. For example, "A" maps to the decimal number 65 or the byte 01000001.
Database field types?
string, text, alpha, number, integer, long, real or date
Two ways to send information securely over internet?
SSL-secured socket layer and VPN-virtual private network
What is the standard by which computers define alphabetical, numerical, and punctuation?
ASCII
What is the acronym for the software that allows computer networks to be used for telephone system?
VoIP/ Voice-over-internet protocol
What is the BLOB used for?
to store image data in a database
abstracting
Data entry of codes and other pertinent information (e.g., patient identification data, admission discharge dates) utilizing computer software.
accreditation
Voluntary process that a health care facility or organization undergoes to demonstrate that it has met standards beyond those required by law.
Accreditation Council for Graduate Medical Education (ACGME)
Professional organization responsible for accrediting medical training programs in the United States through a peer review process that is based on established standards and guidelines.
active
Medical staff member who delivers most hospital medical services and performs significant organizational and administrative medical staff duties.
agenda
Listing of all items of business to be discussed at a committee meeting.
associate
Medical staff member whose advancement to active category is being considered.
biometrics
An identifier that measures a borrower's unique physical characteristic or behavior and compares it to a stored digital template to authenticate the identity of the borrower, such as fingerprints, hand or face geometry, a retinal scan, or handwritten signature.
board of directors
See governing board
board of governors
See governing board
board of trustees
See governing board
bylaws
Rules that delineate medical staff responsibilities.
Centers for Medicare & Medicare Services (CMS)
New name for the Health Care Financing Administration (HCFA), effective in 2001. DHHS agency that administers Medicare, Medicaid, and the Children's Health Insurance Program (CHIP); formerly called the Health Care Financing Administration (HCFA).
chief resident
Position held by a physician in the final year of residency (e.g., surgery) or in the year after the residency has been completed (e.g., pediatrics); plays a significant administrative teaching role in guiding new residents.
Code of Federal Regulations (CFR)
Codification of the general and permanent rules published in the Federal Register by the executive departments and agencies of the federal government.
coding
Assigning numeric and alphanumeric codes to diagnoses, procedures, and services; this function is usually performed by credentialed individuals (e.g., certified coding specialists).
computer-based record (CPR)
Automated record system that contains a collection of information documented by a number of providers at different facilities regarding one patient; has the ability to link patient information created at different locations according to a unique patient identifier; provides access to complete and accurate health problems, status, and treatment data; and contains alerts (e.g., drug interaction) and reminders (e.g., prescription renewal notice) for health care providers. Also called electronic health record, which some professionals prefer as it better describes the method in which the patient record is managed.
consulting
Highly qualified practitioner who is available as a consultant when needed.
continuum of care
Complete range of programs and services, with the type of health care indicating the health care services provided; JCAHO defines the continuum of care as "matching an individual's ongoing needs with the appropriate level and type of medical, psychological, health or social care or service"; contains primary, secondary, and tertiary levels of care.
contract services
Arranging with outside agencies to perform certain functions, such as health information services, housekeeping, medical waste disposal, and clinical services; the purpose of contracting out these services is to improve quality while containing costs.
courtesy
Medical staff member who admits an occasional patient to the hospital.
Current Procedural Terminology (CPT)
Published annually by the American Medical Association; codes are five-digit numbers assigned to ambulatory procedures and services.
Dark Ages
See Middle Ages.
deemed status
Hospitals that are accredited by approved accreditation organizations (e.g., JCAHO) are determined to have met or exceeded Conditions of Participation to participate in the Medicare and Medicaid programs.
deeming authority
When an accrediting organization's standards have met or exceeded CMS's Conditions of Participation for Medicare certification, accredited facilities are eligible for reimbursement under Medicare and Medicaid, and CMS is less likely to conduct an on-site survey of its own.
digital signature
Type of electronic signature that uses public key cryptography. Created using public key cryptography to authenticate a document or message.
do not resuscitate (DNR)
An order documented in the patient's medical record by the physician, which instructs medical and nursing staff to not try to revive the patient if breathing or heartbeat stops.
electronic signature
Encompasses all technology options available that can be used to authenticate a document. Generic term that refers to the various methods an electronic document can be authenticated, including name typed at the end of an email message by the sender, digitized image of a handwritten signature that is inserted (or attached) to an electronic document, secret code or PIN (personal identification number) to identify the sender to the recipient, unique biometrics-based identifier, or digital signature.
Emergency Medical Treatment and Labor Act (EMTALA)
Addressed the problem of hospitals failing to screen, treat, or appropriately transfer patients (patient dumping) by establishing criteria for the discharge and transfer of Medicare and Medicaid patients; also called the anti-dumping statute.
Federal Register
Legal newspaper published every business day by the National Archives and Records Administration (NARA); available in paper form, on microfiche, and online.
governing board
Membership serves without pay and is represented by professionals from the business community; has ultimate legal authority and responsibility for the hospital's operation and is responsible for the quality of care administered to patients; also called board of trustees, board of governors, board of directors.
government-supported hospitals
Not-for-profit, supported by local, regional, or federal taxes, and operated by local, state, or federal governments; also called public hospitals.
Health Care Procedure Coding System (HCPCS)
Comprised of Level I (CPT) and Level II (National) codes.
health care proxy
Legal document (recognized by New York State) in which the patient chooses another person to make treatment decisions in the event the patient becomes incapable of making these decisions.
Health Insurance Portability and Accountability Act (HIPAA)
Mandated administrative simplification regulations that govern privacy, security, and electronic transactions standards for health care information; also protects health insurance coverage for workers and their families when they change or lose their jobs.
Health Plan Employer Data and Information Set (HEDIS)
The National Committee for Quality Assurance (NCQA) "tool used by health plans to collect data about the quality of care and service they provide.
Healthcare Integrity and Protection Data Bank (HIPDB)
Created as part of HIPAA to combat fraud and abuse in health insurance and health care delivery by alerting users to conduct a comprehensive review of a practitioner's, provider's, or supplier's past actions.
Hill-Burton Act
Provided federal grants to modernize hospitals that had become obsolete due to lack of capital investment throughout the period of the Great Depression and World War II (1929 to 1945); in return for federal funds, facilities agreed to provide free or reduced charge medical services to persons unable to pay.
honorary
Retired medical staff member who is honored with emeritus status; also includes outstanding practitioners whom the medical staff wish to honor.
hospital administration
Serves as liaison between the medical staff and governing board and is responsible for developing a strategic plan for supporting the mission and goals of the organization.
hospital departments
Provide direct care as well as ancillary (e.g., clinical laboratory) and support services (e.g., health information department).
house officers
Physicians whose only job is to work at the facility treating patients; they are considered employees of the facility.
Human Genome Project
National coordinated effort to characterize all human genetic material by determining the complete sequence of the DNA in the human genome; in 2000, the human genome sequencing was published.
incomplete record processing
Includes the assembly and analysis of discharged patient records.
intern
Historical term used to designate physicians in the first year of graduate medical education (GME); since 1975, the Accreditation Council for Graduate Medical Education (ACGME) has referred to individuals in their first year of GME as residents.
International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM)
Used in the United States to collect information about diseases and injuries and to classify diagnoses and procedures.
intranet
Private network that utilized Internet protocols and technology and allows users to immediately and simultaneously access health care information with complete security and an audit trail, regardless of where users are located.
Level II (National) HCPCS codes
Developed by the Centers for Medicare & Medicaid Services (CMS) and used to classify report procedures and services.
licensure
Obtaining a license to operate.
living will
Contains the patient's instructions about the use of life-sustaining treatment.
Medicaid (Title 19)
Joint federal and state program that helps with medical costs for some people with low incomes and limited resources. Medicaid programs vary from state to state, but most health care costs are covered for those who qualify for both Medicare and Medicaid.
medical staff
Licensed physicians and other licensed providers are permitted by law (e.g., nurse practitioners and physician assistants) who are granted clinical privileges.
medical transcription
Accurate and timely transcription of dictated reports (e.g., history, physical examination, discharge summary).
Medicare (Title 18)
Health program for people 65 years of age or older, certain younger people with disabilities, and people with End-Stage Renal Disease (ESRD, which is permanent kidney failure treated with dialysis or a transplant).
Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA)
Provides Medicare recipients with prescription drug savings and additional health care plan choices (other than traditional Medicare); modernizes Medicare by allowing private health plans to compete; and requires the Medicare Trustees to analyze the combined fiscal status of the Medicare Trust Funds and warn Congress and the President when Medicare's general fund subsidy exceeds 45 percent.
Medieval medicine
Developed during the Middle Ages (or Dark Ages), its most significant event was the construction of hospitals to care for the sick (e.g., bubonic plague).
minutes
Concise, accurate records of actions taken and decisions made during a meeting.
modern medicine
Characterized by the implementation of standards for sanitation, ventilation, hygiene, and nutrition; in addition, choosing health care as a profession became more acceptable, hospitals were reformed, and training of physicians and nurses improved.
National Practitioner Data Bank (NPDB)
Established by the federal Health Care Quality Improvement Act of 1986. It contains information about practitioner's credentials, including previous medical malpractice payment and adverse action history; state licensing boards, hospitals, and other health care facilities access the NPDB to identify and discipline practitioners who engage in unprofessional behavior.
not-for-profit
Excess income is reinvested in the facility.
ORYX initiative
Introduces by JCAHO in 1997 to integrate outcomes and other performance measurement data into the accreditation process.
Prehistoric Medicine and Ancient Medicine
Characterized by the belief that illness was caused by the supernatural; an attempt to explain changes in body functions that were not understood (e.g., evil spirits were said to have invaded the body of the sick person).
primary care
Services include preventive and acute care that are referred to as the point of first contact and are provided by a general practitioner or other health professional (e.g., nurse practitioner) who has first contact with a patient seeking medical treatment, including general dental, ophthalmic, and pharmaceutical services.
proprietary hospitals
For-profit hospitals owned by corporations (e.g., Humana), partnerships (e.g., physicians), or private foundations (e.g., Tarpon Springs Hospital Foundation, Inc., which does business as Helen Ellis Memorial Hospital in Tarpon Springs, Florida).
public hospitals
See government-supported hospitals
public key cryptography
Attaches an alphanumeric number to a document that is unique to the document and to the person signing the document. Uses al algorithm of two keys, one for creating the digital signature by transforming data into a seemingly unintelligible form and the other to verify a digital signature and return the message to its original form.
quality improvement organization (QIO)
New name for peer review organizations (PROs); QIOs continue to perform quality control and utilization review of health care furnished to Medicare beneficiaries.
record circulation
Includes the retrieval of patient records for the purpose of inpatient readmission, scheduled and unscheduled outpatient clinic visits, authorized quality management studies, and education and research.
regulation
Interpretation of a law; written by responsible regulatory agency such as Centers for Medicare & Medicaid Services (CMS).
resident
Physician who has completed an internship and is engaged in a program of training designed to increase his or her knowledge of the clinical disciplines of medicine, surgery, or any of the other special fields that provide advanced training in preparation for the practice of a specialty.
rules and regulations
Procedures based on federal/state regulations and accreditation standards that clarify medical staff bylaws.
secondary care
Services provided by medical specialists or hospital staff members to a patient whose primary care was provided by a general practitioner who first diagnosed or treated the patient (the primary care provider refers the patient to the specialist).
Shared Visions-New Pathways
Introduced by the JCAHO in 2003 to radically change the survey process so it focuses on whether the organization is making improvements system-wide. Facilities will adopt a continuous survey process starting in 2004, which means survey preparation will be an ongoing process (instead of the traditional once-every-three-years labor-intensive preparation that proved not to impact on improving patient care).
smart card
Plastic card that contains a small central processing unit, some memory, and a small rectangular gold-colored contact area that interacts with a smart-card reader.
standards
Measurements developed by an accreditation organization to evaluate a health care organization's level of performance in specific areas (usually more rigorous than regulations).
State Children's Health Insurance Program (SCHIP)
Health Insurance program for infants, children, and teens that covers health care services such as doctor visits, prescription medicines, and hospitalizations; also called Title XXI of the Balanced Budget Act of 1997.
survey
Evaluation process conducted off-site and on-site to determine whether the facility complies with standards.
Tax Equity and Fiscal Responsibility Act of 1982 (TEFRA)
Established the first Medicare prospective payment system, called Diagnosis Related Groups (DRGs), which was implemented in 1983.
teaching hospitals
Government (not-for-profit), proprietary (for-profit), or voluntary (non-profit) hospitals that are affiliated with a medical school.
tertiary care
Services provided by specialized hospitals equipped with diagnostic and treatment facilities not generally available at hospitals other than primary teaching hospitals or Level I, II, III, or IV trauma centers.
Title XXI of the Balanced Budget Act of 1997
See State Children's Health Insurance Program.
triage
An organized method of identifying and treating patients according to urgency of care required.
universal chart order
Discharged patient record is organized in the same order as when the patient was on the nursing floor; eliminates the time-consuming assembly task performed by the health information department.
veterans
Individuals who have served in the United States military and who are eligible to receive care at VA Medical Centers (VAMCs) located throughout the United States.
utilization management
A person from this department works with case managers of insurance companies to determine the appropriateness of admissions.
utilization management
Committee concerned with appropriate use of resources for providing patient care.
utilization manager
Suzy Staff's job responsibilities include coordinating patient care to ensure that patients receive timely discharge or transfer. Her job title is:
professional standards review organizations, appropriateness, quality, outcomes, medicare, medicaid, maternal and child health
The utilization review process was strengthened in 1972 through the formation of the _______ to monitor the ____, ____, and ____ of services provided to beneficiaries of ____, ____, and _____ programs.
utilization manager
Responsible for coordinating patient care to ensure appropriate utilization of resources, delivery of health care services, and timely discharge or transfer.
case manager
A utilization manager is also known as a:
utilization management
Controls health care costs and the quality of health care by reviewing cases for appropriateness and medical necessity.
quality improvement organizations, quality control, utilization review of health care
In 2002, the CMS announced the establishment of ____ that would continue to perform ____ and _____ furnished to Medicare beneficiaries.
utilization management, costs
PAC (or preadmission testing) in managed care is part of the _______ to contain ______.
quality improvement organizations
QIO
quality improvement organizations
In 2002, PROs were replaced with _____?
free standing facilities
These types of facilities provide ambulatory surgery, clinical laboratory, imaging, infusion, pain management, rehab, primary care and neighborhood health care.
rehabilitation
Hospitals that admit patients who are diagnosed with trauma or disease and need to learn how to function.
CARF
Which organization provides accreditation for rehabilitation?
hospice care
Provides comprehensive medical and supportive social, emotional, and spiritual care to terminally ill patients and their families.
palliative, curative
The goal of hospice is _______care rather than _______ care.
hospice care
A patient with end stage renal disease would be a candidate for _____.
palliative care
Hospice care provides comprehensive medical and supportive care to terminally ill patients and their families. Hospice provides ______.
residential care facilities
Which of the following does Medicare NOT reimburse: home health services, hospice care, residential care facilities, skilled care facilities.
continuing care retirement communities
Provide different levels of care based on the residents' needs from independent living apartments to skilled nursing care in an affiliated nursing facility.
skilled nursing
Facility that provides medically necessary care to inpatients on a daily basis that is performed by, or under the supervision of, skilled medical personnel.
acute care facilities
____________ provide the full range of services including critical care, emergency, surgery, obstetrics, and ancillary services
acute care
A hospital that provides health care services to patients who have serious, sudden, or acute illnesses or injuries and/or need surgeries is _____ facility.
cancer registrar
A ______ is responsible for ensuring the timely, accurate, and complete collection and maintenance of cancer data.
cancer registrars
These individuals use computerized registry software to conduct lifetime follow-up on cancer patients, electronically transmit data to state and national agencies, and generate reports and information for requesting entities.
cancer registrars
These individuals coordinate the national survey process through the ACS commission on cancer and arrange monthly or bi-monthly cancer committee meetings.
data, sources, cancer statistics, government, health care
Cancer registrars collect _______ from a variety of ______ and report _________ to ________ and ______ agencies.
cancer program development support, compliance, reporting standards, resource
Cancer registrars work closely with health care agencies to provide ______, ensure ________ with ________, and serve as a valuable _______ for cancer information.
National Cancer Registrars Association
What organization administers the CTR exam?
coding
The assignment of numbers to diagnosis, services, and procedures based on patient record documentation.
diagnoses, services, procedures, reimbursement, research, statistical
A coding specialist ensures that all ____, ____, and _____ documented in patient records are coded accurately to ensure ____, and for ____ and ____ purposes.
coding specialist
The hospital's quality management department has determined that 10% of the medical staff is noncompliant regarding documentation issues affecting the appropriate assignment of diagnosis and procedure codes. Which professional would best provide in service training in this area?
health information managers
Experts in managing patient health information and medical records, administering computer information systems, and coding diagnoses and procedures.
quality health care
Health information managers organize, analyze, and maintain patient data to ensure delivery of ________.
patient health information, medical records, computer information systems, diagnoses, procedures
Health information managers are experts in managing _______ and _______, administering ________, coding _______ and _______ for health care services.
delivery, quality health care
Patient data is organized, analyzed and maintained by health information managers to ensure the ____ of _____.
risk management
Which committee ensures patient safety by analyzing trends of incidents and establishing priorities for dealing with high risk areas?
tissue
The _____ committee would be responsible for reviewing preoperative and pathologic diagnoses to determine the medical necessity for surgery.
credentials committee
The medical staff committee that reviews and verifies medical staff application data is the _____.
executive committee
This group reviews medical staff applications and recommendations, votes, and makes recommendations to Medical Staff.
committees
Hospital ______________ are multidisciplinary and comprised of representatives from various departments.
risk management
A hospital committee that is responsible for analyzing trends of accidents and establishing priorities for dealing with high-risk areas is ___.
disaster control
Committee responsible for establishing a disaster plan.
health information
Committee responsible for ongoing review of patient records for timely completion and quality of documentation.
quality management
Committee concerned with the quality of care provided to patient.
ethics
Committee that meets as needed in order to discuss ethical problems.
executive
Committee that acts on reports and recommendations from medical staff committees.
associate
Members of the medical staff whose advancement to active category is being considered.
active
Which medical staff membership category includes physicians who deliver most of the hospital's inpatient medical services?
consulting
Highly qualified medical staff that provide expertise in an specific area
courtesy
Medical staff who occasionally admits a patient to the hospital
honorary
Former medical staff held in high regard and honored with emerti status
bylaws
The rules and regulations of the health care organization as guided by federal and state regulations and accreditation standards.
bylaws
Medical staff policies that delineate medical staff responsibilities are called ____.
privacy officer
A health care professional who oversees the development, implementation, maintenance of, and adherence to the organization's policies that cover the safeguarding of patient health information is ______.
privacy, access, patient health information, federal and state laws
A privacy officer oversees the development, implementation, and maintenance of, and adherence to, and organization's policies and procedures covering _____ of and _____ to _____ in compliance with ______.
1983
Diagnosis related groups begun in ____.
predetermined rate, discharge diagnosis
Diagnosis related groups required acute care hospitals to be reimbursed at a ______ according to ________.
TEFRA
This act established the first Medicare prospective payment system which was implemented in 1983. It allowed the implementation of Diagnosis Related Groups.
diagnosis related groups
IPPS uses __________ to classify inpatient hospital cases into groups expected to consume similar hospital resources.
medicare
Diagnosis-related groups were initially introduced by _______.
discharged, passed, transferred, outpatient facilities
Under DRGs, patients are _________ once acute phase of illness has _________. They are then ________ to other _________.
hybrid
Mix of paper and electronic records
manual
Patient record in paper format.
electronic
Computer based patient records
audit trail
Electronic health records will automatically create a list of all changes made to patient documentation. This is called an:
audit
A periodic ______ of the file area should be done on a daily, weekly, or monthly basis.
periodic audit
This is done of the file area to review for misfiles and records that have not been returned within the time period specified by policy.
terminal digit filing
Type of filing systems used in facilities that assign six digit or longer patient numbers.
primary, secondary, tertiary
Terminal digit filing systems divide numbers into three parts: ______, ______, and _____.
right, left
In the terminal digit filing system, numbers are read from ______ to _____.
right
In the terminal digit filing system, the primary number is ______.
middle
In the terminal digit filing system, the secondary number is ______.
left
In the terminal digit filing system, the tertiary number is _____.
100, 100, straight numerical order
In the terminal digit filing system, numbers are divided into _____ primary sections, _____ secondary sections, and then filed in ________ according to tertiary digits.
security, evenly, congestion, large gaps, record shifting, misfiling, transposition, inactive records
Advantages to the terminal digit and middle digit filing system include: (1) high degree of _____; (2) files expand _____; (2) eliminates ______ in file area; (3) ______, _______, _____, and _______ occur less frequently; (6) _______ are easily retrieved as new records are added.
lengthier, space, equipment
Disadvantages to the terminal digit filing system include: (1) training time ______; (2) more _____ and ______ will be needed to organize file area.
middle digit filing
Variation of the terminal digit filing system where the middle digits act as the primary number.
left
In the middle digit filing system, the secondary digits are on _______.
right
In the middle digits filing system, the tertiary digits are on ______.
centralized filing
Type of filing system where patient records are organized in one central location under control of the health information department.
identified, equipment, supplies, space, personnel, one location, services, security
Advantages of the centralized filing system include: (1) responsibility for record keeping easily _______; (2) effective use of _____, _____, _____, and ______ is made; (3) patient records are located in _______; (4) consistent _____ provided to all users; (5) allows improved ______.
decentralized filing
Type of filing system where patient records are organized throughout the facility in patient care areas under control of the department that creates and uses them.
providers, extra space, filing, retrieval
Advantages of the decentralized filing system include: (1) records are located near ______ that create and use them; (2) no ______ is needed in the health information department; (3) providers control _____ and _____.
confusion, fragmented documentation, multiple locations, maintain, uniformity, consistency
Disadvantages of the decentralized filing system include: (1) ______ can occur as to where patient information may be; (2) _______ can result because information may be filed in _______; (3) providers may not know how to properly ______ records; (4) lack of _____ or ______ in record keeping.
30-50-06, 34-50-06, 84-39-20, 12-40-96
Arrange the following numbers in terminal-digit order: 30-50-06; 84-39-20; 12-40-96; 34-50-06
10-31-20, 84-39-20, 12-40-96; 54-40-96
Arrange the following numbers in middle-digit order: 12-40-96; 54-40-96; 84-39-20; 10-31-20
serial numbering
In this system, each time a patient is registered, a new patient number is assigned and a new patient record is created.
serial numbering
This type of filing system is usually used by facilities that don't use computerized ADT software.
different, multiple locations
A disadvantage of a serial numbering system is that records are filed in ______ locations in the filing system. _______ must be accessed to retrieve patient records
serial unit numbering
Type of numbering system where patients receive a new number each time they are registered by the facility and records from previous admission/encounter are reassigned to new number
most current folder, one
In a serial unit numbering system, all patient records are filed in the ______ in _____ location.
remain in, note identifying a new
In a serial unit numbering system, folders that contain previous patient records _______ file and a ________ number is inserted into the folder.
not needed, new, subsequent, previous, one, retrieved, refiled
Advantages to the serial unit numbering system include: (a) computer software is ______ to track assignment of patient numbers; (b) patient is assigned a _____ number for ______ visits and _____ number is brought forward; (c) patient records are filed in ______ location; (c) records are easily _____ and ______.
remain in, note, patient number, thick, cumbersome, multiple
Disadvantages to the serial unit numbering system include: (a) previous folders must ______ file with ______ providing new _______ information; (b) folders can become _____ and _____; (c) ______ folders may be needed to house all records
terminal digit
Sunny View Hospital is part of a large university hospital with a very active and congested file area. Records are filed an refiled throughout the day. Which filing system should be used to distribute the records equally in the file area?
terminal digit
In this type of filing system, the final two digits are the primary numbers.
numbers, patient
Sunny Valley Hospital uses the serial numbering system. The master patient index card should contain all the _____ issued to the ____.
straight numeric filing
Ms. HIM files the following records: 223345, 223346, 223347, 223348. Which system is being used?
02-345678, 05-345678
Happy hospital uses the family numbering system. Tom Short is considered the head of household and is assigned patient number 01-345678. What number would his wife and third born child be?
decentralized
Sunny View Health Care Systems files the records for their clinics at the clinic sites, the ER records on the second floor, and the inpatient records on the fourth floor. The type of filing system used is
discharge orders
Final physician order documented to release a patient from a facility.
discharge order
A patient's record contains the following order: "Mary Black is stable and has no complaint of pain. Wound is healing. No fever or chills. No medications given and no restrictions. She can be released home in the morning. To be seen in my office in two weeks." This is an example of a
discharge progress note
A ______ must be written even if you have a discharge summary.
discharge notes
This is the final progress note that indicates the patient's discharge destination, discharge meds, and follow up plan.
routine order
Physician orders preapproved by the medical staff which are preprinted and placed on the patient's record.
routine, standing
Preprinted physician orders, known as _____ or _____ orders, are preapproved by the medical staff and placed on a patient's record, usually at the time of admission.
stop order
State law mandates, and in absence of state law facilities decide, for which circumstances preapproved standing physician orders are automatically discontinued.
telephone order
Verbal order dictated via telephone to authorized staff member.
history
This document the patient's chief complaint, history of present illness, past, family, and social history.
past history, social history, chief complaint, present illness, review of systems
What are the five major sections of a history?
physical exam
Assessment of the patient's body systems to determine diagnosis.
previous inpatient admission, 30 days, same condition
Documents a patient's history of present illness and any pertinent changes and physical finding that occurred since _______ if patient was readmitted within _____ after discharge for _____
interval history
A 74 year old was readmitted for pneumonia seven days following discharge for this condition. In this case an ____ would be acceptable.
physical exam
If a physician hears that the patient's lungs are congested, he would document it in the _____
clinical resume
A discharge summary is also known as a _________.
hospitalization, diagnoses, procedures, findings, treatment, condition, follow up
Discharge summary should contain the reason for ________, principle/secondary _____, principle/secondary _______, significant ______, type of ______ provided, _____ upon discharge, and instructions for _______.
discharge summary
This provides information for continuity of care and facilities medical staff committee review.
discharge summary
Documents the patient's hospitalization, including reasons for hospitalization; procedures performed; care, treatment, and services provided; patient's condition at discharge; and instructions.
attending physician
The JC requires the discharge summary to be completed by ______.
progress note
In lieu of a discharge summary, final ______ can be made if the patient is treated for minor problems (short stay).
reason for hospitalization, course of treatment, condition at discharge
A discharge summary includes which three things?
administrative, clinical
All patient records contain ________ and _______ data.
administrative
Data that includes demographics, socioeconomic, and financial information.
clinical
Data that includes all patient health information obtained throughout treatment and care of patient.
administrative
Patient name, martial status, place of employment, date of birth, insurance number, and third-party payer are what type of data?
clinical
Physical and history, operative records, lab reports, discharge summary, progress notes are what type of data?
administrative data
Face sheet, advance directives, informed consent, patient property, birth certificate, and death certificate are all ________.
patient registration form
In the physician record, this contains demographic, administrative, and financial data.
administrative data
An advance directive, informed consent, and patient property form are considered
financial, administrative
The patient's insurance information is considered ____ and _____ data.
clinical, case, demographic
Patient records contain _______, ______, and ______ information.
identification, financial, clinical
The face sheet should contain ________, ________, and ________ information.
clinical
This type of information includes admitting diagnosis, principal diagnosis, procedures, condition of patient at discharge, codes.
clinical
First-listed diagnosis is ______ data.
clinical
Data that includes all health care information obtained about a patient's care and treatment.
financial
Insurance policy number is ______ data.
clinical data
An admission clerk enters "right lower abdominal pain" as the admission diagnosis on the face sheet. This information is known as
clinical data
An anesthesiology report is considered
clinical data
All patient information obtained through treatment and care of the patient is called ____
advance directive
Hospitals are required to notify patients age 18 and over that they have the right to have an ________.
patient self determination act
This required that hospital notify patients of their right to have an advance directive.
1990
The patient self determination act was passed in ______.
advance directive notification form
Upon admission, the patient signs an _________ to document that the patient has been notified of their right to have an advance directive.
advance directive
A legal document in which patients provide instructions as to how they want to be treated in the event they become ill and there is no reasonable hope for recovery.
advance directives, implementation, advance directives
Facilities must inform patients, in writing, of state laws regarding ______ and facility policies regarding _______ of ________.
advance directive
The patient record must document whether the individual has executed an _______.
do not resuscitate order
Advance directive that indicates medical professionals should not perform cardiopulmonary resuscitation in the event that cardiac arrest occurs.
CPR, transfer
If the patient is at home or in a nursing home, a DNR order tells medical personnel to not perform _________ and not _______ the patient to hospital.
living will
Advance directive that indicates the kind of health care patient does or does not want under certain circumstances as well as patient's desires for life sustaining treatment.
health care durable power of attorney
Advance directive where patient names someone close to them to make decisions about health care in the event they become incapacitated.
advance directive
A signed document that informs a health care provider of a patient's desire regarding various life sustaining treatment is
advance directive
Written instructions given by a patient to a health care provider outlining the patient's preference for care before the need for treatment is known.
master patient index
Facility keeps a _____ used to locate a patient's record.
alphabetic
Type of filing system that uses patient's last name, first name, and middle initial to file patient records and master patient index cards.
master patient index cards, foreign sounding names
Soundex has been adopted by health care facilities to organize _________ in communities with large populations of _________.
two, patient record, outguide
n a manual tracking system, ______ copies are the paper requisition form are filed; one is attached to the _______ and one is inserted into the _____.
outguide
This replaces the record in the file area to indicate it has been removed and to identify its current location.
outguides
These are beneficial in locating records that have been removed and are unreturned.
demographic data
Patient identification information collected according to facility policy.
demographic data
Patient name, date of birth, place of birth, social security number, make up a patient's __________.
Health record
Principal repository for data and information about the healthcare services provided to an individual patient. who, what, when, where, & why
Data
Represents basic facts about people, processes, measurements, conditons, etc. (facts)
Information
After data has been collected and analyzed and converted into a form that can be used for a specific purpose (meaning)
Personal health record (PHR)
health record initiated & maintained by an individual
healthcare reimbursement
Based on the documentation contained in the health record
Quality improvement organizations (QIO) & utilization management organizations
evaluate the adequacy & appropriateness of the care provided by healthcare organizations
Centers for Medicare & Medicaid (CMS)
responsible for administering the ferderal MC program and federal portion of MA program. Used to be called HCFA-health care financing administration until 2001.
Data applications
the purposes for which data are collected
Data collection
the processes by which data are collected
Data warehousing
The processes & systems by which data are archived (saved for future use)
Data analysis
Process by which data are translated into information that can be used for designated application
Data quality management
*Accuracy
*Accessibility
*Comprehensiveness
*Consistency
*Currency
*Definition
*Granularity
*Precision
*Relevancy
*Timeliness
Data accuracy
Means data are correct. Should represent what was intended or definied by the original source of the data
Data accessibility
Means that the data are easily obtainable
Data comprehensiveness
means that all required data elements are included in the health record
Data consistency
Means that the data are reliable
Data currency/timeliness
Means that healthcare data should be up-to-date & recorded at or near the time of the event or observation
Data definition
Means that the data & information documented in the health record are defined
Data granularity
Requires that the attributes & values of data be definied at the correct level of detail for the intended use of the data
Data precision
Term used to describe expected data values
Data relevancy
Means that the data in the health record are useful
Privacy
Right of individual to control access to their personal health information
Confidentiality
Refers to the expectation that the personal information shared by an individual with a healthcare professional during the course of care will be used only for its intended purpose
Security
The protection of the privacy of individuals & the confidentiality of health records
Connectivity
Refers to the capacity of health record systems to provide communicaton linkages & allow the exchange of health record data among information systems
Health record format
refers to the organizations of electronic information or paper forms within the individual record
Source-oriented health record format
format that organizes the information according to the patient care department that provided the care (used in most acute care hospitals)
Problem-oriented health record format
Format that is a documentation approach in which the physician definies each clinical problems individually. organized into 4 components: database, problem list, initial plans, & progress notes
Integrated health record format
Format that organized all the paper forms in strict chronological order & mixes the forms created by different departments
Health record
Represents the main communicatoin mechanism used by healthcare providers. Tool for documenting patient care
Clinical data
documents the patient's medical condition, diagnosis, & procedures performes as well as the healthcare treatment provided
Administrative data
included demographic & financial as well as various consents & authorizations related to the provision of care & the handling of confidential patient information
Conditions of participation/coverage
Standards that are applied to facilities that choose to participate in MC and MA
Registration record
Documents demographic information about the patient
Medical history
Documents the patient's curent & past health status
Physical examination
Contains the provider's findings based on exam of the patient
clinical observation
Provides a chronological summary of the patient's illness & treatment as documented by physicans, nurses, and all allied healthcare professionals
Physician's orders
Document the physician's instructions to other parties involved in providing the patient's care including orders for medications and diagnostic/therapeutic procedures
Reports of diagnostic & therapeutic procedures
Describes the procedures performed and give the names of providers, includes findings of x-ray, mammograms, ultrasounds, scans, lab tests, & other diagnostic procedures
Consultation reports
Document opinions about a patient;s condition furnished by providers other than the attending physician
Discharge summary
concisely summarizes the patient's stay in the hospital
patient instructions
Document the instructions for follow-up care that the provider gives to the patient or patient's caregiver
Consents, authorizations, & acknowledgements
Documents the patient's agreement to undergo treatment or services, permission to release confidentialy information, or recognition that information has been received
Provisional diagnosis
Admitting or working diagnosis identified by the condition or illness for which the patient needs medical care
Chief complaint
Nature & duration of the symptoms that caused the patient to seek medical attention as stated in his/her own words
Present illness
Detailed chronological description of the development of the patient's illness, from the appearance of the first sympton to the present situation
Past medical history
Summary of childhood & adult illness & conditions, such as infectious diseases, allergies & drug sensitivities, accidents, operations, hospitalizations, & current medications
Social & personal history
marital status, dietary, sleep, & exercise patterns, use of tobacco, coffee, alcohol, & other drugs, occupation, home environment, daily routine, etc.
Family medical history
Diseases among relatives in which heredity or contact might play a role
Review of systems
Systemic inventory designed to uncover current or past subjective symptoms
Progress notes
Purpose is to create a chronological report of the patient's condition & response to treatment during their hospital stay and serve to justify further acute care treatment in the facility
Care plan
Summary of the patient's problems from the healthcare professional's perscpective for a specific patient admission & discharge documenting the patient's condition at regular intervals throughout the hospital stay
Implied consent
Is consent assumed by the patient voluntarily submitting to treatment
Expressed consent
consent that is either spoken or written
Anesthesia report
includes any preoperative medication & response to it, the anesthesia administered with dose & method of administration, the duration of administration, patient's vital signs under anesthesia, & any additional products given to the patient during the procedure
operative report
report that describes the surgical procedures performed on the patient
recovery room report
Report that includes the postanesthesia note, nurses notes regarding the patient's conditon & surgical site, vital signs, IV fluids, and other medical monitoring
Pathology report
Report dictated by pathologist after exam of tissue received for evaluation includes description of tissue from a macroscopic level & representative cells at microscopic level along with interpretive findings
Consultation report
Report documenting the clinical opinion of a physician based on his/her exam of patient at the request of attending physician
discharge summary
Concise account of the patient's illness, course, of treatment, response to treatment, & conditon at time of discharge. includes instructions for followup care
Transfer record/referral form
Report that includes a brief review of patients acute stay along with current status, discharge, & transfer order & additional orders sent to the facility patient being transferred to.
Autopsy report
Report that contains a description of the exam of a patients body after death
Demographic
The study of the statistical characteristic of human population
Authorization
Permission granted by the patient or patient's representative to release information
Consent
Term used when the permission is for treatment, payment, or healthcare operations
authorization to disclose information
Term used to allow the healthcare facility to verbally disclose or send health information to other organizations
Advance directive
Written document that that names the patient's choice of legal representative for healthcare purposes. the person is then empowered to make healthcare decison on behalf of the patient in the event the patient is not capable of expressing his/her preferences
patient self-determination Act (PSDA)
Requires healthcare facilities to provide written information on the patients rights to execute advance directives & to accept or refuse medical treatment. went into effect in 1991.
Resident assessement instrument (RAI)
Based on minimum data ses for long-term care includes the MDS, triggers, utilization guidelines, & resident assessment protocols.
Outcomes & Assessment information set (OASIS)
Foundation for the plan of care. MC uses this to determine payment
Basic principles of health record documentation
principles address the uniformity, accuracy, completeness, legibility, authenticity, timeliness, frequency, & format of health record entries
Deemed status
Status obtained after facilities receive accreditation from agencies such as Joint Commission
Det Norske Veritas (DNV)
International accreditating organization
Integrated health record
health record is arranged so that documentation from various sources is intermingled in strict chronological order
Personal health record
An electronic record of health-related information on an individual that conforms to nationally recognized interoperabiity standards & that can be drawn from multiple sources while being managed, shared, & controlled by the individual
Qualified EHR
Includes patient demographic & clinical health information such as medical history & problem lists, & has capacity to provide clinical decision support, support physician order entry, capture & query information relevant to healthcare quality, & exchange electronic health information with & integrate such information form other sources
Computer-based patient record (CPR)
A system specifically designed to support users thru availability of complete & accurate data, practitioner reminders & alerts, clinical decision support, links to bodies of medical knowledge, & other aids
Electronic medical record
An electronic record of health-related information on an individual that can be created, gathered, managed, & consulted by authorized clinicians & staff within ONE healthcare organization
Electronic health record
An electronic record of health-related information on an individual that conforms to nationally interoperability standards & that can be created, managed, & consulted by authorized clinicians & staff across MORE THAN ONE healthcare organization
evidence-based medicine
The practice of medicine that utilizes guidance-based information gleaned from research studies
Portal
special application to provide secure access to a specific application such as a physicians office to a hospital
Interface
special software that aids formatting of data for transmission among systems with a hospital, lab, or other providers. special program where specific data are identified as needing to be exchanged & then rules about how those data are structured are applied.
Discrete data/structured data
Consists of data elements that are raw facts or figures that can be processed by the computer such as lab values
Textual data
physicians describe patient conditions in narrative form
Computer output to laser disk (COLD) also referred to as electronic document/content management ED/CM systems
Systems that capture print images of lab results & other documents that are in a stand-alone electronic systems & make them available for viewing on a computer monitor
Electronic signature authentication (ESA)
System that require the author to sign into the system using a user ID & password, reivew the document to be signed, & indicate approval.
Clinical data repository (CDR)
A special kind of database that manages data from different source systems in the hospital or other provider settings, including direct entry of discrete data by the clinician.
Templates
Ensure that the appropriate data are collected & guide users in adhering to professional practice standards
Practice guidelines
Recommendation based on what experts believe should be done
Evidence-based guidance
Drawn from scientific research & clinical trials
Electronic medication administration record systems (EMAR)
An application that identifies when a drug is administered & aids in documenting the administration
Barcode medication administration record (BC-MAR)
Five rights of patients: right patient, right, drug, right time, right dose, & right route
Health information portability & accountability act (HIPAA) 1996
Encouraging the development of health information systems thru the establishment of standards & requirements for electronic transmission of certain health information.
identity matching algorithm
algorithm uses sophisticated probability equations to identify patients
Record locator service (RLS)
Process that seeks information about where a patient may have a health record available to the organization
national health information infrastructure (NHII)
Set of technologies, standards, applications, systems, values, & laws that support all facets of provider healthcare, individual health, & public health
natiinwide health information network (NGIN)
provide the technology to support national health information infrastructure. goal establish privately financed consortium to ensure public policy goals are execute & rapid adoption of interoperability is applied.
Meaningful use
Ability to demonstrate quality improvements thru use of EHR
Interoperabilty
Refers to the use of standard protocols to enable 2 different computers to share data with each other
Pay for performance (p4P) or pay for quality (P4Q)
Insurance company incentives to providers to reward data collections & in reporting clinical outcomes
Registry
Collection of specific data form a predefined data set which are used to dvelop reports across multiple patients
Integrated or tethered Personal health record
Generally integrated with an existing EHR in a hospital or clinic system
Automated personal health records
Health plans started offering these PHR that are largely controlled by provider or health plan with limited data entry directly by the patient
stand-alone or untethered personal health records
may be paper or automated often acquired thru a commercial vendor ususally thru a Web site
Database
organized collection of data
Relational database
stores data in predefined tables that contain rows & columns similar to spreadsheet
Database management system (DBMS)
Software that organize, provide access to, & otherwise manage a database
Clinical data warehouse (CDW)
Form of database that are optomized to perform analysis on date on many different things at one time. used to analyze a large set of clinical data
data exchange standards/ message format standards/ interoperability standards
makes sure the interface is written correctly & the exchange of data occurs reliably
Protocols
Defined ways to do something
DICOM
helps exchange clinical images such as x-rays, CT, scans, etc.
National Council for prescription drug programs (NCPDP)
Enable the communicaiton of retail pharmacy eligibility inquiries & claims and exchange of prescriptions from physicians office
American national standard institute (ANSI) Accredited Standards committee X12 (ASC X12)
Provides standards for hospital, professional, & dental claims, eligibility inquiries, electronic remittance advice, & other standards
ASTM international
E31 Committee on health information has developed guidelines primary for various EHR management processes
Data comparability
Terms must have same meaning from one clinical system to another
Semantics
Term used to describe fact that value of the data in the message has standardized meaning. message format standard specifies vocabulary which data is encoded
Standard vocabulary
Developed thru a process that confirms consensus on meaning of the term included in the vocabulary
SNOMED International
most comprehensive effort to standardize vocabulary for representation of medical knowledge, incorporates microglossaries that address nursing & other ancillary terminology
Vocabulary
Refers to the set of all terms that may be used in a language
classification
Grouping of the terms into various categories such as diseases of respiratory system
logical observation identifies, names & codes (LOINC)
provides names & codes for lab test results & other observations
RxNorm
Provides description of medications in clinical form
Universal medical device nomenclature system (UMDNS)
Provides standard terminology for medical devices
National drug codes (NDC)
used to maintain inventories of drugs in pharmacies or links to CPT in physicians offices
enterprise report management ((ERM)
Captures data from print files & other report-formatted digital documents such as emails
results retrieval
may be basic lookup where a query is made to access certain data from specific system such as lab results
Results management sytem
results retrieval technology couples with CDR permits not only viewing of data by type but also manipulation of several different types of data such as plotting lab results on graph against medication administered, vital signs, etc.
Human-computer interface
Technologies that make data capture easier for ex. point & click, drop down menus, etc
Discrete data
Entry thru point & click fields, drop-down menus, structured templates, or macros. make data entry & processing easier.
Natural language processing (NLP)
Takes narrative text & converts to structured data
Architecture
Refers to the configuration, structure, & relationships of all components of computer system
Client/server architechture
uses combination of computers to capture & process data.
Local area networks (LAN)
Using hardware cable transmit data securely at very high speeds thru out a building, campus, or small geographic area
Wireless local are network (WLAN)
utilize radio waves or microwaces to transmit data without cable. ex. is bluetooth that beams data using infrared light. IrDA ports must be in close proximity. RFID similar to barcode scanning but can be done greater distance.
Wide area network (WAN)
Data are transmitted across wide geographic areas general depend on high density trunk lines such as T-1 or T-3
Wireless wide area network (WWAN)
Mobile communications cellular network technologies such as 3G
TCP/IP transmission control protocol/internet protocol
most healthcare organization use this to simplify their networking and to take advantage of web-based technology
Intranet
A LAN that uses TCP/IP
Redundant array of independent disks (RAID)
inexpensive disks used as a storage media
Server redundancy
accomplished thru mirrored processes means that data set are entered & processed by 1 server, they are entered, & processed simultaneously by a second server
audit logs
is element of retention schedule
dual core
vendor strategy where one vendor supplies the financial & administrative applications & another vendor supplies the clinical applications
process improvement
Series of actions taken to identify, analyze, & improve existing processes
Chart conversion
Process whereby data from paper chart are converted to electronic form
Data conversion
Ensures that data in one system can be converted over to new system
Unit testing
Ensures that each data element is captured, recorded, & processed appropriately within a given application
System testing
Tests the various parts of the applications work together within a system work
Stress testing
Peformed toward the end of implementation to ensure the acutal number or load of transactions that would be performed during peak hours can be performed
Acceptance testing
Done at the end may be a review of all tests performed, assurance that all issues resolved, and some measure of adoption. final payment usually at this point
Authentication systems
Access controls, audit logs, & other measures for security
Encryption
Process that converts human readable data into a format that cannot be read except with a special process to decrypt the data
Metadata
includes data & file attributes, audit logs, software codes, temporay information such as sticky notes & alerts, pop-ups, & even some information about system maintenance
Health information management (HIM)
An allied health profession that is responsible for ensuring the availability, accuracy, & protection of the clinical information that is needed to deliver healthcare services & make appropriate healthcare-related decisions.
American Health information management association (AHIMA)
The provessional membership organization for managers of health record services & healthcare information systems as well as coding services; provides accreditation, certification, & educational services.
Institute of Medicine (IOM)
Branch of the National academy of sciences whose goal is to advance & distribute scientific knowledge with the mission of improving health.
Computerized provider order entry (CPOE)
Provides physicians & other providers the ability to order via the computer from any number of locations & adds decision support capability to enhance patient safety.
Accreditation Associaton for Ambulatory health care (AAAHC)
Professional organization that offers accreditation programs for ambulatory & outpatient organizations such as single or multipspecialty group practices, ambulatory surgery centers, college/university health services & community health centers
Accreditation commission for heatlh care (ACHC)
private, nonprofit accreditation organization offering accreditation services for home health, hospice, & alternate site healthcare such as infusion nursing, & home/durable medical equipment
American assoiciation for accreditation of ambulatory surgery facilities (AAAASF)
an organization that sets standards for accrediting ambulatory surgical facilities
American osteopathic associaton (AOA)
professional association of osteopathic physicians, surgeons, & graduates of approved colleges of osteopathic medicine that inspects & accredits osteopathic colleges & hospitals
commission on accreditation of rehabilitation facilities (CARF)
private,not for profit organization that develops customer-focused standards for behavioral healthcare & medical rehab programs & accredits such programs on the basis of its standards
Minimum data set for long-term care (MDS)
the instrument specified by CMS that requires nursing facilities (both MC/MA certified) to conduct a comprehensive, accurate, standardized, reproducible assessemtn of each resident's functional capacity
National committee for quality assurance (NCQA)
private, not for private accreditation organization whose mission is to evaluate & report on the quality of managed care organizations in the US
patient assessment instrument (PAI)
standardized tool used to evaluate the patient's condition after admission to, and discharge from, the healthcare facility
resident assessment protocol (RAP)
Summary of a long-term care residents medical conditions & care requirements
SOAP
An acronym for a component of the problem-oriented medical record that refers to how each progress note contains documentation relative to subjective observation, objective observation, assessments, & plan
DNR
Do not resuscitate
DNI
Do not attempt intubation
ICF-MR
Intermediate care facility for mentally retarded/disabled
Integrated delivery systems (IDS)
system that combines the financial & clinical aspects of healthcare & uses a group of healthcare providers, selected on basis of quality & cost management criteria to furnish comprehensive health services across the continuum of care
regional health information organization (RHIO)
health information organization that brings together healthcare stakeholders within a defined geographic area & governs HIE among them for the purpose of improving health & care in the community
national alliance for health information technology (NAHIT)
partnership of government & private sector leaders from various healthcare organizations working to use technology to achieve improvements in patient safety, quality of care, & operating performance founded in 2002.
American recovery & reinvestment act (ARRA)
previously known as stimulus bill or HR 1. action related to HIT are spread throughout the law however bulk of the items are in title XIII or HITECH
Clinical decision support (CDS)
the process by which individual data elements are represented in the computer by a special code to be used in making comparisons, trending results, & supplying clinical reminders & alerts
clinical document architecture (CDA)
HL7 electronic exchange model for clinical documents such as discharge summaries & progress notes
clinical information systems (CIS)
category of healthcare information system that includes systems that directly support patient care
Continunity of care document (CCD)
combines the content that physicians have agreed should be included in patient referrals with a means to format that data for electronic transmission
Continunity of care record (CCR)
documentation of care delivery from one healthcare experience to another
disease management (DM)
more expansive view of case management in which patients with the highest risk of incurring high-cost interventions are targeted for standardizing & managing care throughout integrated delivery systems
electronic data interchange (EDI)
standard transmission using strings of data for business information communicated among the computer systems of independent organizations
electronic document/content manager (ED/CM)
type of electronic document management system that uses methods such as bar coding on the forms to identify specific content
electronic document management system (EDMS)
storage solution based on digital scanning technology in which source documents are scanned to create digital images that can be stored on optical disks
Extensible markup language (XML)
standardized computer language that allows the interchange of data as structure test
health information exchange (HIE)
health information is shared among providers
HITECH
the part of AARA that is meant to increase the momentum of developing & implementing EHR by 2014
health level 7 (HL7)
standards development organization accredited by the American national standards institute that addresses issues at the 7th or application level of healthcare system interconnections
Hospital information system (HIS)
comprehensive database containing all the clinical, administrative, financial, & demographic information about each patient served by a hospital
Medicare modernization act of 2003 (MMA)
legislation passed in 2003 designed to expand healthcare services for seniors with major focus on prescription drug benefits
national alliance for health information technology (NAHIT)
partnership of government & private sector leaders from various healthcare organizations working to use technology to achieve improvements in patient safety, quality of care, & operating performance founded in 2002
national committee for quality assurance (NCQA)
private, not for profit accreditation organization whose mission is to evaluate & report on the quality of managed care organizations in the US
national library of medicine (NLM)
world's largest medical library & branch of national institute of health
Office of the national coordinator (ONC) for HIT
provides leadership for the development & implementation of an interoperable health information technology infrastrurture nationwide to improve healthcare quality & delivery
Pharmacy benefit manager (PBM)
vendor selected by bureau of workers comp to process outpatient medication bills submitted electronically
picture archieving & communications system (PACS)
integrated computer system that obtains, stores, retrieves, & displays digital images of radiological images
point of care (POC)
place or location where physician renders care to the patient
practice management system (PMS)
software designed to help medical practices run more smoothly & efficiently
Primary care physician (PCP)
physician who provides, supervises, & coordinated the healthcare of a member & who manges referrals to other healthcare providers & utilization of healthcare services both inside & outside a managed care plan
protected health information (PHI)
all individually identifable information oral or recorded in any medium that is created or received by a healthcare provider or any other entity subject to HIPAA requirements
regional health information organization (RHIO)
health information organization that brings together healthcare stakeholdres within a defined geographic area & governs HIE among them for the purpose of improving care & health in the community
request for proposal (RFP)
correspondence asking for a very specific product or contract information
storage area network (SAN)
storage devices organized into a network so that they can be accessible from any server in the network
Problem list
List of illnesses, injuries, & other factors that affect the health of an individual patient, usually identifying the time of occurrence or identification & resolution
Migration path
A series of steps required to move from one situation to another. Plan that describes what systems will be implemented and what order the transition to the EHR will follow.
Primary users of health records
physicians, nurses, & all allied health professionals that provide medical care
operative report contains?
*patients preoperative & postoperative diagnosis
*description of procedures performed
*description all normal/abnormal findings
*decription of patients medical condition before, during & after operation
*estimated blood loss
*description of specimens removed
*description any unique/unusual events during surgery
*names surgeons & assistants
*date & duration of surgery
What setting includes bereavement counseling?
Hospice
ambulatory care record whose funciton is to facilitate ongoing patient care management?
problem list