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HIT 110 - Chapter 1-4, 8 & 9, 12 & 13

Introduction, Purpose and Function, Content and Structure Of Health Record, Electronic Health Record, Health Information Technology Functions, Secondary Data Sources, Healthcare Delivery Systems, Ethical Issues
STUDY
PLAY
HIM has been recognised as an allied healh profession since:
1928
The hospital standardization movement was inaugurated by the
American College of Surgeons
Throughout the years, HIM roles have
Become more focused
The traditioinal model of HIM practice was
Department based
The new model of HIM practice is
Information focused
What evolving role oversees the process that begins at the time of documentation through billing:
Revenue Cycle Management
The organization that accredits HIM Program is:
CAHIM
What evolving role assesses quality in health record banking?
Health Record reviewer
Purpose: to ensure the quality, confidentiality and availability of health information across diverse organizations, settings and disciplines
AHIMA
What is the purpose of the Hosptial Standardization Program?
to raise the standards of surgery by establishing minimum quality standards for hospitals.
What did the ACS realize?
that the most important item in the care of any patient was a complete and accurate report of the care and treatment provided during hospitilization.
Who is responsible for the accredidation of academic and certificate programs for HIT?
CAHIIM (Commission on Accredidation for Health Informatics and Information Management Education
AHIMA was orignially named?
ARLNA
What is the primary focus of AHIMA
To foster the professional development of its members through education, certification and lifelong learning.
Active members of AHIMA include those who:
Hold an AHIMA credential
Who functions as the legislative body of AHIMA
House of Delegates
Who promotes education and research?
CAHIIM
The virtual network used by AHIMA members is:
Communities of Practice
How many types of memberships are there in AHIMA
3
WHat does the volunteer component of AHIMA do:
Establishes the organizations missions and goals, develops policy and provides oversight for the organizations operations.
What does the staff component of AHIMA do?
Carries out the operational task necessary to support the organizations missions and goals
Who leads the volunteer structure of AHIMA and has the responsibility for managing the property, affairs and operations.
Board of Directors
Must be active members, are elected by the membership and serve three year terms.
Board of Directors
Who is responsible for overseeing AHIMA's certification process and for setting policies and procedures?
CCHIIM (Commission on Certification for Health Informatics and Information Management)
Makes up a virtual network of AHIMA memebers who communicate via a Web-based program called
Communities of Practice (CoP)
Functions as AHIMA's legislative body and conducts the official bysiness of the organizations
House of Delegates
Who elects the representatives to the House of Delegates?
Each state HIM Association
The following: Approving Standards, Guide to Interpreting the Code of Ethics, Electing members of AHIMA Nominating Committee, Advising the Board of Directors, Levying Special Assessments, Approving ammendments to AHIMA by laws, Approving resolutions is the responsibility of
House of Delegates
Provide members with local access to professional educationn, networking, and representation, are a forum for communicating information relevant to national issues, informing members of regional affairs that affect health information management
CSA's (Component State Associations)
AHIMA headquarters are located in?
Chicago
Who can sit for the RHIA and RHIT exams?
People who have graduated from and accredited and aproved program
To achieve certification from AHIMA do what?
Meet eligibilty reguirements and complete the certifcation exam.
A program of earned recognition for AHIMA members who have made signigicant and sustained contributions?
Fellowship Program
We had 324 Medicare patients last month - this statement represents:
Data
I am a patient - Information from myself and my physician on my medical history is stored on the internet. What am I?
EHR (eletronic health record)
The principal repository that documents the who, what, when, where, why and how of patient care.
Health Record
Represents the basic facts about people, processess, measurements,and conditions
DATA
What represents meaning
Information
Health Record initiated,maintained and owned by an individual is called
Personal Health Record (PHR)
Healthcare information created and maintained iteractively, used by healthcar providers.
Electronic Health Record (EHR)
What is the primary purpose of a health record
Patient care management
The secondary purpose of a health record is for?
Related to environment where healthcare services are provided
In reference to medical records patient care delivery, patent care management, patient care support processess, financial and other administrative processess, patient self managment are all examples of what purpose?
Primary Purpose
In reference to medical records education (teaching and documentaition), regulation (litigation, assess compliance and comparisons), research (Clinical), Public health and homeland security (monitor public health), policy making and support, industry (research and development) are all examples of what purpose?
Secondary Purpose
Submitting documetation to a third party for substantiating a patients bill is considered what purpose
Primary
Using a health record to study effectiveness of a given drug is considered what purpose
Secondary
Physicians, nurses, clinical personnell, therapists, respiratory, lab and radiology technicians, patients, families, unit clerks, administrators, quality managers, benefit managers, insurers, accreditors, lawyers, researchers represent what type of users of health records?
Individual Users
Healthcare delivery organizations like physician practices, ambulatory clinics, rehab and long term facilities, public health departments, disease registries, research centers, medicare peer review, employers, insurers, edcuational institutions, accredidation, federal, local and governmental agencies represent what type of users of health records?
Institutional User
Details taken from individual health records and then all information is put together in one place is called what type of data?
Aggregate
Who would utilize Aggregate data to identify patterns and trends in patient care facilities?
Patient Care Managers
Individuals who enter, verify, correct, analyze, or obtain information from the record, either inderctly or directly through an intermediary are what?
Users of Health Records
Medical records that are used as a tool to protect the legal interests of facility and for litigation would be used by who?
Lawyers
Health records used in the investigation of gunshot injuries, child abuse, domestic violence and other crimes are used by who?
Law Enforcement Officals
The review of health records for a particular population being studied and extract data, used to evaluate and make decisions about disease procese and treatments would be used by?
Healthcare Researchers and CLinical Investigators
Patient care information aggregated by researchers and investigators to generate consumer reports would be used by?
Healthcare Science Publishers and Journalist
Aggregate information taken from a health record and used for the basis of investigations of health patterns and trends in a given population - used to develp and fund community programs are used by?
Government Policy Makers
Information taken from a medical record and used for the evaluation of adequacy and appropriatenes of care provided, and to determine whether services were medically necessary would be used by?
Medical Review Organizations
Medical records used in healthcare related research and study to prove or disprove hypothesis related to disease processess and treatments would be utilized by?
Research Organizations
Medical records that are used as a source for case studies would be used by?
Educational Organizations
Medical records that are used to review documentation of patient care services to determine whether the standards for care are being met would be utilized by?
Accredidation Organizations
Medical records used to determine whether a facility is complying with the licensing regulation in a geographic area are used by?
Govenrment Licensing Agencies
Data taken from health records and then used to make decisions related to Healthcare reimbursement, effectiveness of healthcare services and the general health of Medicare populations is utilized by?
CMS (centers ofr Medicare and Medicaid Services)
Who develops and test experimental patient care protocols?
Research Organizations
What is the primary function of the health record?
To store patient care documentation
To accomplish the primary and secondary purposes of a health record the data must be?
of the Highest Quality
The HIM professionals most important role is to ensure that the health record contains....
The highest quality data possible
Data applications, data collection, data warehousing and data analysis are the four domains of:
Data Quality Management
The purposes for which data is collected is?
Data Applications
The processes for which data is collected is?
Data collections
Process and system in which data is archived
Data Warehouseing
Process in which data is translated into information that can be used is?
Data Analysis
Accuracy, Accesibility, Comprehensiveness, Consistency, Currency, Definition, Granularity, Precision, Relevancy, and timeliness are characteristics of?
Data Quality Management
Data that is correct and represents what was intender or defined by original source is
Data Accuracy
Data that is easily obtainable
Data Accesibility
All required data elements are included in the health record and is complete.
Data Comprehensiveness
Data that is reliable and values are consistent - data does not change due to storage, process or display and values are the same on any application and system
Data Consistency
Healthcare data is up to date and recorded at time or near time of the event or observations
Data Currency and Data Timeleness
Information and data in the health record is meaningful and pertinent, has clear definition and range of acceptable values
Data definition
That data attributes and values be defined at the correct level of detail for the intended use
Data Granularity
Expected data values - yields accurate data collections
Data Precision
Data in the health record is useful - reason for collecting the data is clear
Data Relevancy
The right of the individual to control acces to their personal information is defined as
Privacy
The expectation that personal information shared by an individual with a provider during care is used only for its intended purpose defines...
Confidentiality
Program designed to protect patient privacy and to prevent unauthroized access, alteration or destruction of health records
Security
The capacity of health record sytems to provide communication linkages and allow the exchange of health record data amoung information system defines...
Connectivity
Source orientated health record format, Problem orientated health record format and Integrated health record format are commonly used in...
Paper based record systems
Organizes the patient information according to the patient care department that provided the care. Are grouped together according to their point of origin. (lab grouped, radiology grouped, etc.)
Source-orientated Health Record Format
Documentation approach where the phsyician defines each clinical problem individually and then organized into database, problem list, initial plans and progress notes. Each problem is indexed with a unique number.
Problem Orientated Health Record Format
Organizes all paper forms in strict chronological order and mixes the forms created by different departments. Easy to follow course of the patients diagnosis and treatment, but is difficult to compare similar types of information due to the format.
Integrated Orientated Health Record Format
Acute Care Hospitals use which paper based format system?
Source Orientated
A combination of paper based records and electronic records.
Hybrid Health Record
In reference to electronic health records - having timely access to all types of results (lab, radiology) represents what clinical tool in the EHR model
Results Management
What system helps providers to eliminate lost orders, illegible handwriting, duplicate orders, medication errors, and reduction in time filling orders
CPOE (Computerized provider order entry)
CPOE were developed to improve quality of care and represent what clinical tool and function of the EHR model
Order-Entry/Order Managment
Is more than a simple repository of patient care data, alert practioners to our-of-range lab values or dangerous trends, access to pharmaceutical formularies, referral databases and reference literature is what clinical tood and function of the EHR model
Clinical Decision Support
A tool for documenting patient care and for patient caregivers to commmunicate with each other
Health Record
Health records has two types of data?
Clinical and Administrative
Patients medical conditions, diagnosis and procedures performed and treatement provided represents what type of data?
Clinical Data
Demographics,financial information, consents and authorizations represent what type of data?
Administrative Data
What content is found in the medical record is determined by?
The needs of the practice and pertinent standards
Standards found in facility policies and procedures, medical staff bylaws, rules and regulations is what type of source?
Facility-Specific Standard
State or County regulation that healthcare facilities must meet to be permitted to provide care?
Licensure
Facilities that are certified and participate in Medicaid and Medicare
Government Reimbursement Programs
Standards that are applied to facilities participating in Government Reimbursement programs are called
Conditions of participation or Coditions for Coverage
Indication that a facility has voluntarily met the standards of an independnet accredidation organization
Accredidation standards
Documented in the health record are Medical History, Physical Examination, diagnosis, orders, clinical observations, reports, and discharge summary these are also known as?
Clinical Data
Documentation of patients current compliants an symptoms, past medical, personal and family.
Medical History
Assessment of patients current health status is found in the....
Physical Examination Report
Instructions given to healthcare profesionals to perform diagnostic test, treatments, medications and specific services to a particular patient are called...
Physicians orders
Documentation by nurses, physicians and other care givers stating patients condition and response to treatment are found.......
Progress notes
A summary of the patients problems with a detailed plan for interventions is called a
Care Plan
Results for laboratory tests, pathological examinations, radiological scans are documented and called
Diagnostic Reports
Before a procedure is performed whose responsibility is it to make sure the patient understands the nature of a procedure, alternative treatments and risks and complications
Physicians
Preoperative medication and responses, anesthesia administered with dose and method, duration and vital signs can be found in what type of report
Anesthesia Report
Describes the surgical procedures, diagnosis, normal and abnormal findings, blood loss, medical condition, specimens removed, unusual events, names of surgeons, assistants and date and duration of surgery
Operative Report
Post anesthesia note, nurse note on condition, vital signs, surgical site and any meds or IV are noted in what type of report?
Recovery Room Report
Report that is dictated after examination of tissue received for evaluation, describes tissue and interpretive findings
Pathology Report
The clinical opinion of a physician other than the primary or attending physician
Consultations Report
A concise account of a patients illness, course of treatment, response, includes instructions for follow up care
Discharge Summary
Discharge summary is the responsibility of and must be signed by.....
Attending Physician
Prenatal care summary, admission evaluation, record of labor, info on contractions, fetal heart tones, examination of birth canal, medications and vital signs are all part of what type of records
Obstetric Delivery Record
Financial information maintained in the acute care health record lis limited to ........
Insurance Information
Before providing routine services, diagnostic procedures and medical care what is obtained from the patient
Consent to treatment
What rule requires provides to secure a patient's written acknowledgement that they received notice of providers privacy practices...
Privacy Rule
Permission granted by the patient to release information for reasons other than treatement, payment or healthcare operations is called
Authorization
Permission for treatment, payment or healthcare operations is called
Consent
What allows a facility to verbally disclose or send health information to other oranizations
Authorization to disclose information
A written documnet that names the patients choice of legal representative for healthcare purposes - designated and empowered to make all healthcare decisions on behalf of the patient if they are no longer capable is called
Advance Directive
Living wills and Durable Powers of Attorney for healthcare are examples of...
Advance Directives
What should be consistent advance directives in reference to Physicians orders
DNR and DNI
What specialized type of progress note provides healthcare professionals impressions of patient problems with detailed treatment actions steps
Care Plan
Written or spoken permission to proceed with care is
Expressed consent
Sleeping patterns, head and chest measurements, feeding and elimination status, weight, and Apgar scores are recorded in what type of Record
Newborn
Who issues specific health information standards for Acute Care Hospitals
Joint Commision
Rehabilitation hospitals use the standards of...
CARF (Commission on the Accredidation of Rehabilitation Facilities)
Care provided in a physicians office, group practices, clinics, outpatient facilities, public health, industrial health and urgent care settings as well as receiving care through HMO's, PPO's, and IPA's all fall under what type of documentation
Ambulatory Care Documentation
What unigue records are found in Ambulatory Documentaion that aren't found in Acute Care
Problem List and Patient History Questionaire
In the ambulatory documentation record any significant current and past illnessess, conditions, surgeries and procedures as well as allergies and drug sensitivity - can be found where?
Problems List
A structured form used to collect past medical history and information from the patient in an Ambulatory setting
Patient History Questionaire
Skilled Nursing Facilities, Subacute care facilities, Nursing facilities, Intermediate Care Facilities, mentally disabled and retarded facilities and assisted living facilities all fall under what type of care classification?
Long Term Care
SNF's and NF's and ICF's are governed by
Federal and State regulations and Medicare Conditions of Participation
Assisted living facilities are goverened by
State Regulations
Care Plan for SNF facilities that is reguired by the federal government, is based on the Minimum Data Set (MDS), includes triggers, utilization guidelines and RAP's, is a critical component of the health record. This care plan format is called?
RAI (Resident Assessment Instrument)
RAP's stands for
Resident Assessment Protocol
Home care agencies that accept Medicare are governed by
Federal Regulations
Medicare certified home healthcare use a standardized patient assessment instrument called?
OASIS (Outcomes and Assessment Information Set)
Hospice programs provide what type of care
Palliative Care
Patient care that focuses on symptom management and patient comfort versus life prolonging measures is
Hospice Care
Standards for facilities that specialize in mental health, mental disabilities and developmental disabilities can be found with what organizations?
CARF and AOA
Increasing a patients ability to function as independently as possible within the parameters of the individuals illness or disability is the focus of what type of service?
Rehabilitation Services
Reahbilitation facilities reimbursed by Medicare use what type of care plan format?
PAI (Patient Assessment Instrument)
What type of healthare record contains information about care provided prior to arrival at a healthcare setting and documentation of care provided to stabilize the patient?
Emergency Care
Patient history questionaires, problem lists, diagnostic test results, and immunizations records are found in which type of record?
Ambulatory Care
Amublatory surgical record contains inforamtion most similar to?
Hospital Operative Record
Which standardized tool is used to assess Medicare-certified rehabilitation services?
PAI ( Patient Assessment Instrutment)
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 patients 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 in which type of record?
Behavioral Health
Growth and development record may be found in what type of record
Pediactric
What document indicates current and past medical conditions?
Problem List
Before granting accredidation and certification regulatory agencies use what as a tool to measure the quality of services?
Documentation
Facility specific standards, licensure requirements, government reimbursement standards and accredidation standards are known as the four main sources of....
Documentation guidelines
What is required in order for Healthcare organizations to begin or remain in operation within their states?
Compliance with State licensing laws
Joint Commission, NCQA and DNV are what
Accreditation Organizations
AOA, AAAHC and CARF are what
Accredidation Programs
NCQA
National Committee for Quality Assurance
Focus on patient safety, confidentiality, consumer protection, access to services, service quality and continous improvement.
NCQA (National Committee for Quality Assurance)
AAAHC
Accredidation Association for Ambulatory Health Care
AOA
American Osteopathic Association
DNV
Det Norske Veritas an international accrediting organization
NAIHO
National Integrated Accredidation for Healthcare Organizations
An accrediting organization that is awarded deemed status by medicare means that the facilities receiving accredidation under it's guidelines do not need to....
Undergo Medicare certification surveys
What group focuses on accredidation of managed care and preferred provider organizations?
NCQA (National Committee for Quality Assurance)
Which of the following regulations would most likely contain information on who is authorized to enter documenation in a patients record?
Facility rules and regulations
What organization has instituted a health record - prohibited abbreviation list
Joint Commission on Accredidation of Healthcare Organizations (JCAHO)
What conforms to nationally recognized interoperability standards - can be used across more than one health care organization
Electronic Health Record
Patient health information and data are stored in a single central computer system - this is known as what type of database model?
Centralized Record (model)
Patient health information and data are located in department based computer systems or subsytems this is known as what type of database model?
Distributed Record (model)
Continuous voice recognition, optical character readers, barcode readers, document imaging are types of?
Data capture or Data Input
Includes both paper and electronic documents and uses both manual and electronic process
Hybrid Record
What is a disadvantage of an EHR over a paper based record?
Privacy and Security Measures
An intergrated health record, documentation by health professionals is organized?
Intermixed in date sequence
Entry relates ignificant information in the patients words or from their point of view - this represents what part of the SOAP format?
S - Subjective
Data includes factual information like laboratory findings or provider observations - this represents what part of the SOAP format?
O - Objective
Professional conclusions from evaluation or objective information due to assessment - represents what part of the SOAP format?
A - Assessment
Comments on or changes in plans - makes up what part of the SOAP format?
P - Plans
A definition of what constitutes a record, recording where each component is located, and noting dates of format changes are important in what type of record?
Hybrid Record
In a problem orientated health record problems are organized by?
Number
Health Level 7 (HL7) have guidelines that address which aspect of the electronic health record?
Definition of functions
Which tyupe of data input mechanism is commonly used in both paper and electronic environments?
Transcription
Progress notes of physicians, nurses, therapist and other authroized individuals would be found together in chronological sequence in what type of record?
Integrated Record
Which part of the medical history documents the nature and duration of the symptoms that caused a patient to seek medical attentions and is stated in the patients own words?
Chief Complaint
What determines who can receive and transcribe verbal orders?
Medical Staff Bylaws
Presentation of data, quick search capabilities, need to know and analytical capabilities are all factors that should be considered when designing what type of system for an EHR
Data Retrieval
What type of facility is not governed by Medicare long term care documentation standards?
Assisted Living Facilities
What specialized patient assessment tool must be used by Medicare certified home care providers?
OASIS ( Outcomes and Assessment Information Set)
Which regulation is most commonly applied in end stage renal disease treatment?
Medicare Conditions for Coverage
Planning and managing care, evaluating the adequacy and appropriateness of care, substantiating reimbursement claims and protecting the legal interests of both patient and healthcare provider represents the functions of:
the Health Record
What federal law resulted in the new privacy and regulations for healthcare organizations?
The Health Insurance Portability and Accountability Act
A transition technology used by many hospitals to increase access to medical record content?
EDMS (Electronic Document Management System
What was developed to eliminate data inconsistencies when patients were referred from one provider to another?
CCR (continuity of care record)
What system requires the author to sign on using an ID and pasword, reveiw the document to be signed and then indicate approval?
ESA system (Electronic SIgnature Authentication)
EHR systems are based on a special kind of database that manages data from different source systems and combines them into one location for easier processing - this is called?
CDR (Clinical Data Respository)
An application that provides context-sensitive templates to ensure that appropriate data is collected is known as ....
Point of care charting
A database devoted to the collection of data from scientific purposes and is used to support CDS systems is called?
Knowledge Databases
An application that identifies when a drug is to be adminstered and aids in documenting the administration is called....
EMAR (Electronic Medication Administrations Record)
A system that is also known as the 5 rights of medication administrations is called..
Barcode Medication Administration Record (BC-MAR)
Due to the barcode the nurse is able to identify the right patient, the right drug to be given, at the right time, in the right dose, via the right route. This is referred to as the....
Five rights of medication administration
An application that uses standard order sets, and gives immediate feedback as to drug contraindications, appropriate protocol for diagnostic studies, etc...this is known as.....
CPOE (Computerized Provider Order Entry)
All elements of medication selection, dispensing, administration and monitoring are aided by computerized support is called...
Closed Loop Medication Management
A system used by nursing and physicians to document assessments and findings is called....
Patient care charting
Dr. Smith always orders the same 10 things when a new patient is admitted, in addition to some patient specific orders. What would tool would assist in assuring that the specific patient is not allergic to a drug being ordered?
Knowledge Databases
What system provides alerts and reminders to clinicians?
Clinical Decision Support System
Drop down menus, check boxes, type-ahead and other data entry aides are utilized to ensure that appropriate data is collected and characterizes what tool?
Templates
Refers to the use of standard protocols to enable two different computer systems to share data with each other.
Interoperability
An exchange of a standard set of health information content between providers and with patients is facilitated by?
CCD (Continuity of Care Document)
In order to locate electronic records for a patient across a health information exchange you would need to utilize what tool?
Indentify matching algorithm and record locator service
Sophisticated probability equations are used to identify patients by HIE organizations to for whom data is to be exchanged this is called what process?
Identify matching algorithm process
Proces that seeks information about where a patient may have a health record is called?
RLS (Record Locator Service)
What criteria is used for Meaningful Use?
HL7 EHR system functional requirements
An organized collection of data is called?
A Database
Stores data in predefined tables that contain rows and columns similar to a spreadsheet - it stores currency, real numbers, integers and strings - this is called.....
Relational Database
A software that organizes, provides accessto and manages a database is called?
Database Management Systems (DBMSs)
Databases that are optimized to perform analysis of data or to analyze a large set of clinical data are called?
Clinical Data Warehouses (CDWs)q
What determines the retention schedule and location of storage
Nature of the data
Health Level Seven (HL7), DICOM, NCPDP, ANSI and ASTM International are organizations that have developed....
Data Exchange Standards
Ensuring that the meaing of a term is consistent across all users is called
Data Comparability
A specific set of terms in the EHRs data dictionary is used and a central authority approves any additions or changes this is called?
A controlled vocabulary
A process that confirms consensus on the meaning of the terms included in the vocabulary - helps to achieve data comparability - this is called
A Standard Vocabulary
Refers to the set of all terms that may be used in a laguage
Vocabulary
A grouping of the terms into various categories
Classifications
The configuration, structure and relationships of all components of a computer system is referred to as
Architecture
A combination of computers to capture and process data, powerful processors
Clint/server architecture
An emerging architecture that utilizes web based tools to permit communication among different software applications
Web Services Architecture
Hardware cable that transmits data securely at high speeds though a building, campus or small geographical area is called
LAN (Local Area Networks)
Utilizes radio waves or microwaves to transmit data without a cable
WLAN (Wireless local area networks)
Data is transmitted across wide geographic areas
WAN (Wide area networks)
What would be needed to accomplish managing the storage and retrieval from e-mail and fax ?
Enterpricse Report Management
A computer that has minimal processing capability of its own is called
Thin Client
A human computer interface that captures data via point and click fields and drop down menus is called what type of interface?
Discrete Data Entry
A system that enables processing of diagnostic studies results into table graphs or other structures is called
Results retrieval and management technology
What technology would reduce the risk that information is not accesible during a server crash
Server Redundancy
Standards for hospital, professional and dental claims, eligibility inquiries, electronic remittance advice and other standards are provided by
ACS X12
A family of standards that aid the exchange of data among hosptial systems, physicians practices and provider sytems is provided by
Health level seven (HL7)
Helps exchange clinical images - xrays, ct scans, etc. is provided by
DICOM (Digital Imaging and Communications in Medicine)
Who enables the communication of retail pharmacy eleigibility inquiries and claims, provides a standard for the exchange of prescriptions from a physicians office directly to a retail pharmacy
NCPDP (National Council for Prescription Drug Programs)
Maintains inventoris of drugs in pharmacies, current procedural terminology (CPT) used to code physician services for reimbursement
NDC (National Drug Codes)
The primary benefits of EHR's are
Quality and patient Safety
A strategic plan that outlines the major components to be implemented, describes phase of implementation with specific goals
Migration Path
A situation where most systems are from one vendor - is usually a major investment in replacing all the source systems for finding the EHR components that will work with current vendor - this is called
Best of Fit
Where one vendor supplies the finacial and adminsitrative applications and another vendor supplies the clinical application this strategy is called?
Dual Core
A strategy where applications from different vendors were selected because it was the best in its class are called
Best of breed
A fair amount of automation in the care delivery organization, poor level of funtctionality - a better single system is probably as cost effective as living with indadequate systems tnis is called?
Rip and replace strategy
A detailed plan that identifies hundreds or thousands of steps that are needed to implement each apoplication is called what type of plan
Implementation Plan
A series of actions taken to identify, analyze and improve existing processess is called
Process Improvement
Process where data from the paper chart is converted into electronic form is called
Chart Conversion
The proces that ensures that data in one sytem can be converted over to the new system is called
Data Conversion
At each phase of installation testing is performed to ensure that each data element is captured, recorded, and processed appropriately within a given application - this is called
Unit Testing
The process that test that the various parts of the applications are working together within a single system is called
System Testing
What ensures that the interfaces between application and systems are working
Intergration Testing
Is performed towards the end of implementation to ensure that the actual number, or load of transactions that would be performed during peak hours can be performed is called
Stress Testing
At conclusion of all testing, some time after go-live - is a review of all test performed, assurance that all issues have been resolved and some measures of adoption is what form of testing
Acceptance Testing
Not satisfied with the information currently have, decided to replace everything with products from one vendor - this strategy is called?
Rip and Replace
Hardware is placed on back-order and the network team is having trouble getting the network to function properly - Addressing these issues is called?
Issues Management
What type of testing ensures that the system can handle a large number of user?
Stress Testing
What type of strategy uses one vendor for clinical and one vendor for Administrative?
Dual Core
Use of comment fields and potential for discrepancy between what is entered as structured data and comment fields, determining if entries are made by legitimate users, handling ammendments, corrections and deletions are all what type of isues?
Data Quality
Data integrity and data availabitlity are the
CIA of Security
Ensuress that data is not altered as they are stored and transmitted electronically
Data Integrity
Refers to how data is stored, backed up and protected in any disruption to the information systems due to syste flaw causing unplanned downtime, los of power, fire, flood or other disater
Data Availability
Confidential information that organizations covered by law and their business associates must protect is called
Protected Health Informatioin (PHI)
Generated at or for a healthcare organization as its business record and is the record that would be released upon request is defined by AHIMA as the
Legal Health Record
Data and file attributes, audit logs, software code, temporary information like sticky notes, alert pop ups, information maintenance, activity logs and virus protection are considered to be
Metadata
The CIA of security includes confidentiality, data integrity and
Data Availability
Specific policies and procedures on users and disclosures of PHI, individuals privacy rights, and privacy management, increasing enforcement actions and penalties, making business more accountable, has added a data breach notification requirement and provisions relating to unsecured PHI - all of this is governed by
HITECH
Audit logs and alert pop-ups are examples of
Metadata
Makes data entry easier but may harm data quality?
Copy and paste function
A copy of every form used by a healthcare facility to document patient care in the paper based record is placed in a
Forms Catalog
the act of seeing what process in a current workflow could be eliminated and what new process would need to be implemented is called
Workflow Analysis
Information centered, information quality, security and availability, clinical quality performance, research and statistics, maintenance of registries and release of information are all functions of
HIM
One of the most important indexes, functions as the primary guide to locating demographic information and the health record number of patients
Master Patient Index (MPI)
A permanent record of every patient ever seen in a healthcare entity
MPI
A situation where a patient is assigned another patients medical record number is called an
Overlay
A situation where more than one medial record numbers exist for the same patient is called
Overlap
Is a key data element in the MPI, a unique personal identifier, is used in paper-based numerical filing systems to locate records and is assigned at patient registration.
Health Record number (Medical Record number)
Serial Number System, Unit Numbering System, Serial Unit Numbering System and Alphabetic Identification and Filing Systems are
Identification Systems used with EHR's
Patient receices a unique numerical identifier for each encouter to a facility - numbers are issued in a series - each visit is filed seperately this is what type of Identification System
Serial Numbering System
Most commonly used in large healthcare facilities. Patient receives a unique health record number at first encounter and used for each encounter thereafter - works best in a computerized environment - all visits are kept together - this is what type of identification system?
Unit Numbering System
Numbers are assigned in a serial manner, each visit previous records are brought forward and filed under latest assigned health record creating a unit record - This is what type of identification system?
Serial Unit Numbering System
The patient's last name is used as the first source of identification, first name and middle initial provide further identification
Alphabetic Identification System
The patient name and what are used to find a patient's health record that is stored electronically.
Patient Account Number
A sytem in which a health record number is assigned at the first encounter and then used for all subsequent encounters is
Unit Numbering System
The primary guide to locating a record in a numerical filing system is the
Master Patient Index
Ongoing process to identify and address existing errors, Advanced person search capabilities, Mechanisms for detecting, reviewing and resolving potential errors, Ability to reliably link different medical record numbers and consideration of the types of physical merges should all be included in what type of maintenance program
Comprehensive MPI Maintenance Program
Which identification sytem is at a disadvantage when there are two patients with the same name?
Alphabetic
The most common numbering system used in healthcare is
Unit numbering system
Using the patients health record number as the primary identifier, clinics, hospitals, long term care facilities and larger facilities file their records in what way
Numerically
Records are filed by using the health record number and is a type of indirect filing system this is what type of filing system
Numeric Filing System
What is the authority file in healthcare?
MPI
Straight Numeric filing system, terminal digit filing system and middle digit filing system are all types of
Numeric Filing Systems
Records are arranged consecutively in ascending numeric order
Straight Numeric Filing
Is the most efficient, the last digit or group of last digits is the primary unit for filing, then the middle unit followed by the last unit of numbers. Last numbers represent the file section, the middle unit represents the shelf number and the last unit represents the folder number. This is what type of filing system
Terminal Digit Filing
The primary unit is the middle unit and the secondary unit is the first unit to the left followed by the last digits - this is what type of filing system
Middle Digit Filing
A combination of alpha letters and numbers for identification purposes - is appropriate for small organizations utilizes the first two letters os patients last name followed by a unique numeric identifier - this is what type of filing system
Alphanumeric Filing System
12-34-55, 13-34-55 and 14-34-54 - what type of filing system is being utilized
Terminal digit filing
Which filing system is considered to be the most efficient
Terminial digit filing
This format stores each document page sequentially in a long roll - it is called.
Roll Mircofilm
This format a roll of microfilm is cut and placed into special four by six jackets with several sleeves to hold the images, jackets can be color coded and can be a unit record - it is called.
Jacket Microfilm
Can be a copy of a microfilm jacket or a direct copy of the source health record, made of mylar film and the same size as a microfilm jacket - this is
Microfiche
What type of paper based storage system conserves floor space by eliminating all but one or two aisles?
Mobile Filing Units
What feature of the filing folder helps to locate misfiles within the paper based filing system?
Color Coding
What microfilm format is ineffecient when patients have multiple admissions on microfilm?
Roll
The most common type of tracking system to track paper based medical records, is made of strong colored vinyl with two plastic pockets, is the size of a medical record folder and is placed in the location of the record removed, it has a tab the states the word OUT to indicate that the medical record has been removed
Outguide
Policies and procedures that relate to what information must be retained, for how long and in what form are
Rentention policies and procedures
Policies and procedures that relate to what information may be destroyed, appropriate destruction methods and required documentation of destruction are
Destruction policies and procedures
Should be done in accordance with federal and state law and written retention and destruction policies of the organization - except records involved in open investigations, audit or litigation - this pertains to
Destruction
Burning, shredding, pulping and pulverizing are appropriate methods for destroying....
Paper records
Recycling and pulverizing are appropriated methods for destroying.....
Microfilm or microfiche
Magnetic degaussing is the preferred method for destroying......
Computerized data and magnetic tapes
Under the false claims act, claims may be brought up to how many years?
Generally 7 years but could go as high as 10 years
Record retention should be based on
State regulations and AHIMA recommendations
What tool is used to track paper-based health records?
Outguide
The process of assuring that all records of discharged patients have been received by the HIM department for processing is called
Record Reconciliation
Each page of the patient record is organized in a pre-established order refers to....
Assembly
After record is assembled it is reviewed or analyzed to make sure there are no missing reports, forms or required signatures and that all documents contain the patients name and health record number - this reveiw for deficiencies is called
Quantitative Analysis
Personnel who go to the nursing units daily to reveiw each patient record is a process called
Concurrent Reveiw
When the analysis is done following the patients discharge then it is called
Retrospective Review
A supplement to a signed report that provides additional health information to address a specific situation or incident - this is called an
Ammendment
Provides oversight for the development, review, and control of forms and computer screens - What committee does this
Forms design committee
What should be done when the HIM's departments error or accuracy rate is deemed unacceptable?
A Corrective Action should be taken
Statements that define the performance expectations and/or structutres or processess that must be in place are
Standards
In a paper based system, individual health records are organized ina pre-established order called
Assembly
Reviewing a health record for missing signatures and medical reports is called
Analysis
Reveiwing the record for deficiencies after the patient is discharged from the hospital is an example of what type of review?
Retrospective Review
Encompassess a wide range of technologies used to provide portions of an electronic health record and is a commonly used system in the hybrid environment
EDMS (Electronic Document Management System)
Involves removing a document from standard view, removing it from one record and posting it to another - this is called
Retraction
Moving a document from one place to another within the same episode of care is called
Resequencing
Moving the document from one episode of care to a different episode of care within the same patient record is called
Reassignement
The process of checking individual data elements, reports or files against each other to resolve discrepancies in accuracy of data and information
Record Reconciliation
One of the advantages of an EDMS is that is can....
Help manage work tasks
Which term indicates that a document has been removed from standard view...
Resequencing
The process of checking individual data elements, reports or file against each other to resolve discrpencies
Reconciliation
The narrative unstructured data - is the result of a person typing data into a word processing system and should be limited in an EHR environement - this is called
Free-text data
Identification, Authenticfication and Authorization are the foundations of
Access Control
Basic building block of access control is
Identification
The act of verifyinf a claim of identiy is called
Authentication
The right or permission given to an individual to use a computer resource or specific applications and access specific data is called
Authorization
Version control of documents in the EHR requires
Policies and procedures to control which version is displayed
How are records from other facilities used in clinical decision making documented in the EHR
They are scanned and filed in the EHR
What term verifies claim of identity
Authentication
How are ammendments handled in the EHR
Must have seperate signature, date and time
A software program that help guide the coder through the carious coding conventions and rules to arrive at a correct diagnosis, procedural or service code is called an
Encoder
Software that helps coders determine the appropriate ambulatory payment classification for an outpatient encounter is
APC Groupers
Softwar programs that help coders determine the appropriate dianosis-related gorup assignment based on the logic of the system for hospital inpatients is called
DRG Groupers
Several processes working together to ensure that the healthcare facility is properly reimbursed for the services provided is what type of system
Revenue Cycle Managment
A specific index that is essential for locating health records to conduct quality improvement and research studies as well as for monitoring quality care
Disease and Operation Indexes
A guide to identifying medical cases associated with a specific physician is what type of index
Physician Index
A chronological listing of data is known as a
Register
A health information managment department that is not contained within the walls of a traditional facility is called a
Virtual HIM
Accrediting body that has established standards for health record documentation
Joint Commission
A plan that converts the organizations goals and objectives into targets for revenue and spending are referred to as
Budgets
If one needed to know the number of C-sertions performed by a specific obstetrician - what index would you use to identify the cases
Operation index
The coputer system that may serve as the MPI function is the
Patient Registration System
Where does the health record begin at
Patient Registration
One of the most sought after accreditatioin distinction by healthcare facilities is offered by
Joint Commissioin
Statement that describe general guidelines that direct behaviour or direct or constrain decision making are called
Policies
Departmental budget is both an evaluation tool and what other type of tool?
Planning
A person who oversees the completeness and accuracy of the data abstracted for inclusion in the database or registry is called a
Data Steward
Documentation about a patient provided by the professionals who provided the care or services to a patient and is found in a health record is considered what type of source
Primary Data Source
Data taken form a health record and entered into registries and databases are considered what type of sourc
Secondary Data Source
Data on groups of people or patients without identifying any particular patient individually is known as what type of data
Aggregate Data
Aggregate data is conisdered to be what type of source
Secondary Data Source
Quality, performance, patient safety, research, population health and administration are purposes for collecting......
Secondary data
What type of secondary users are located within the healthcare facility and are included in medical staff, administrative staff and managment staff
Internal user
What type of secondary users are located outside the facility and are state data banks, and fereal agencies
External Users
Bob Smit a 56 year old male is an example of what type of data?
Patient Specific
State infectious disease reporting is an example of how what type of user utilizes secondary data?
Internal
Assisting researchers in determining the effectiveness of treatements is what type of data?
Secondary Data
A registry or database is what type of data source?
Secondary
A listing in diagnosis code number order for patients discharged from the facility - diagnosis are converted from a verbal description to a numberical code - what type of index is this?
Disease Index
Is arranged in numerical order by the patients procedure codes using CPT codes - what type of index is this?
Operation Index
Collections of secondary data related to patients with a specific diagnosis, condition or procedure - are different from indexes they contain for extensive data this is called
Disease Registries
Each registry must define the cases that are to be included - this process is called
Case Definition
What is the next step in acquisition after cases that to be included has been determined?
Case Finding
A method used to identify the patients who have been seen and/or treated in the facility for a particular disease or condition of interest to the registry - this is
Case Finding
Information provided is used for the improved understanding of cancer, including its cause and methods of diagnosis treatment this type of data is from
Facility-based Registries
Emphasis is on indentifying trends and changes in new cases of cancer within the area covered by the registry this type of data is from
Population-based Registries
When a case is first entered in the registry what type of number is assigned.
Accession Number
A new standardized staging system that uses algorithms to describe how far a cancer has spread is called
Collaborative Stage Data Set
A database of medical malpractice payments, adverse licensure actions, professional review actions can be found in
NPDB (Nationial Practitioner Data Bank)
A database that contains a collection of information on healthcare fraud and abuse is known as the
HIPDB (Healthcare Integrity and Protection Data Bank)
Research projects in which new treatments and tests are investigate to determine whether they are safe and effective are called
Clinical Trials
A list of rules and procedures to be followed for clinical trials is called
Protocols
After the type of cases to be included in a registry have been determined, what is the next step in data acquisition?
Case Finding
In addition to collecting patient data what other activities do registries engage in?
Reporting and follow up
Why is the MEPAR file limited in terms of being used for research purposes?
It only contains Medicare Patients
The National Practitioner Data Banks was mandated by what establishement?
Health Care Quality Improvement Act
The advantage of HCUP is that it
Contains data on all payer types
An information system developed by an outside company and sold to a variety of organizations is called a...
Vendor System
An information system developed within the facility for its own use is known as
Facility-Specific System
Data accuracy is also referred to as
Data Validity
Methods used to ensure validity is to incorporate what into the database. They check on accuracy of data and data types.
Edits
Another factor in data quality is consistency which is sometimes referred to as
Data Reliability
Having more than one person abstract data for the same case where results are then compared to identify any discrepancies is a method of checking reliability called
Interrater Reliability
Another factor of data quality is comprehensiveness also known as
Completeness
Healthcare data should be up-to-date, must be available within a certain time frame that is helpful to the user this is known as
Data timeliness
Efforts to control access to health information is referred to as
Data Security
A method of scrambling data so that they cannot read without first being decoded is called
Encryption
Efforts to guarantee of privacy of personal health information is referred to as
Data Confidentiality
The degree to which patients included in secondary data sets are aware of their inclusion refers to
Transparency
Using uniform terminology is a way to improve
Data Reliability
Malware is a threat to
Data Security
What type of tool is used to check the quality of data entered into an information system?
Edits