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RHIT Exam Domain 1
Terms in this set (123)
alphabetic filing system
for sm clincic, last name,first name & middle intitial, direct, easy,
alphnumeric filing system
uses letters and numbers
numeric filling system
uses health record number, authority is MPI
A filling system that organizes files by numbers instead of names. Each patient is assigned a number in the order in which she joins the practice.
straight numeric filing systems
aranged consecutively in ascending numeric order, health record # assigned
terminal-digit filing system
most efficient,last digit is the primary # used to file, heavy voulme, even file expansion unlike straight or numeric ex. 36-45-99, 37-45-99, 38-45-99. 99 is the primary unit for filing, 45 is secondare (middle) and 36 is tertiary (folder)
middle-digit filing system
similar to terminal using the middle number as primary
matching between a source and a target sucha as between tow databases that containd the dame data elements but have different names
extracting info from a database & then quantifying and filtering discrete structured data
data that represent separte and sistinct values or obsevation (1,2,5,) not (3.4,.098)
"it was great fun"
discrete = 5 continuous 3.265 either way
data are correct
The health record states that the patient is a female, but the registration record has the patient listed as male. Which of the following characteristics of data quality has been compromised in this case
Which of the following is not a characteristic of high-quality healthcare data?
The extent to which healthcare data are obtainable.
Presence of all required data elements
The extent to which healthcare data are complete
When all required data elements are included in the health record, the quality characteristics for ____________ is met.
The extent to which healthcare data are reliable.
At admission, Mrs. Smith's date of birth is recorded as 3/25/1948. An audit of the electronic health record system discovers that the numbers in the date of birth are transposed in different record reports. This situation reflects a problem in:
The extent to which data are up-to-date.
Refers to data being recorded at or near the time of the event or observation.
CQI, defined meanings and values of all elements so all present and future users understand the data
The attributes and values of data should be defined at the correct level of detail
The extent to which data have the values they are expected to have
The extent to which healthcare-related data are useful for the purpose for which they were collected
data quality improvement
Retrospective audits and corrective actions
Subjective Objective Assessment Plan
a system of organizing information in a medical record
Evaluation and Management services are provided in what standard format
Existing in the mind or relating to one's own thoughts, opinions, emotions, etc.; personal, individual, based on feelings
(adj) factual, related to reality or physical objects; not influenced by emotions, unbiased
Within the SOAP method of charting what section would the diagnosis of the disease go under?
steps in action
structure and content standards
Information standards that provide clear descriptors of data elements to be included in computer-based patient record systems are called ____ standards.
ASTM Standard E1384-02a 07
Standard that identifies the content and structure for EHRs, covering all types of healthcare services, including acute-care hospitals, ambulatory care, skilled nursing facilities, home healthcare, and specialty environmentsEDMS
Electronic documetn management systems, magange many types of digital doc
added to EDMSs, facilitates various functions that must be performed, simultaneously or specific sequence, pg 974
One hospital discharge abstract systems were developed and their ability to provide comparative data to hospitals was established, it became necessary to develop:
List of recommended data elements that include a uniform definitions
Uniform Hospital Discharge Data Set, inpatient
Mary Smith, RHIA, has been charged with the responsibility of designing a data collection form to be used on admission of a patient to the acute care hospital in which she works. The first resource that she should use is ______.
An initiative of TJC that implements 5 core measures to improve safety and quality of health care.
Uniform Ambulatory Care Data Set, outpatient
This is the minimum core data set collected on Medicare and Medicaid outpatients. consults with
minimum data set, long term care
Minimum Data Set (MDS) for Long-term care. The instrument specified by CMS that requires nursing facilities (both Medicare certified and/or Medicaid certified) to conduct a comprehensive, accurate, standardized reproducible assessment of each resident's functional capacity
managed care, Healthcare Effectiveness Data and Information Set
The data set designed to organize data for public release about the outcomes of care is ___________.
Data Elements for Emergency Department Systems
Mary Smith, RHIA has been asked to work on the development of a hospital trauma data registry. Which of the following data sets would be most helpful in developing this registry?
used to gather data about Medicare beneficiaries receiving home care.
Data set required of home health care agencies.
HHC home healthcare for medicare
National Health Information Network
a system of nationally shared health data, comprised of a network of providers, consumers, and researchers, that aims to improve health care delivery through the secure exchange of information
A descriptive list of the names, definitions, and attributes of data elements to be collected in an information system or database whose purpose is to standardize definitions and ensure consistent use. benefit programmers
National Committee on Vital and Health Statistics
office of the national coordinatior of HIT
National Center for Health Statistics
National Cancer Data Base, jointly sponsored by the american colleg of surgeions & american cancer society
healthcare data sets have two purposes
identify the data elemtns that should be collected for each pt
provide uniform definitions for common terms
which is not a characteristic of the sommon healthcare data sets such as UHDDS & UACDS?
answer - they provide a complete and exhaustive list of data elements that must be collected pg 145
system that classifies morbidity and mortality
Compare values across a few categories
Shows the part to the whole
time graph, A graph that uses line segments to show changes that occur over time frequency distribution
An axis-type graph in which data points are joined by a line.
like bar graphs, have no space between them, displays data that fall into groups or categories, displays freg=quency distribution
graph of a frequency distribution that shows the number of instances of obtained scores, usually with the data points connect by straight lines
bar char sorted highest to lowest - decending order
Represents related data as a series of dots.
-show the relationships among the numeric values in several data series
shows relationships among three values by using bubbles
purpose of data sets
identify the data elements that should be collected for each patient and toprovide uniform definitions for common terms
A review of the health record to determine its completeness and accuracy - review for deficiencies
... A review of the health record while the patient is still hospitalized or under treatment.
analysis performed the day after the pt's discharge from the hospital
The arithmetic average of a distribution, obtained by adding the scores and then dividing by the number of scores.
A measure of center in a set of numerical data.
Mid point number
The value that occurs most frequently in a given data set.
Distance between highest and lowest scores in a set of data.
A measure of spread within a distribution (the square of the standard deviation). difference between two numbers
Continuity of Care Record
which of the folllowing should be used to communcate info from one provider to another for referral, transfer, or discharge of the patient
ASTM - E2369-05e2
identified a core data set for a pt's clinical summary related to CCR
Which of the following tools is usually used to track paper-based health records that have been removed from their permanent storage locations?
formula for retrieval and file hrs
600/60 = 10, 600/40 =15 10+15=25 hrs per day
Average daily census formula
total patient days/days in the month
average length of stay formula
total length of stay (discharge days)/ total discharges (includes deaths)
percentage of Occupancy
total service days for a period/total bed count days in the peroid X100
Hospital Death Rate (Gross)
# of deaths of inpt in a period/ # of discharges (including deaths) X100
Gross Autopsy rate
# of inpatient autopsies/#inpatient deaths x 100
Net autopsy rate
total autopsies/total inpatient deaths - unautopsied casesX100
Hospital autopsy rate (adjusted)
the total number of autopsies performed by a hosptial pathologist for a given time period divided by the number of deaths of hospital patients (inpatients and outpatients) whose bodies were available for autopsy for the same periodX100
Fetal death rate
A proportion that compares the number of intermediate and/or late fetal deaths to the total number of live births and intermediate or late fetal deaths during the same period of timeX100
Neonatal Mortality rate (death rate)
total # of newvborn deaths for a period/total # of newborn infant discharges (including deaths) for a periodX100
Maternal Mortality Rate (death rate)
total # of direct maternal deaths for a perod/total # of obstetrical discharges (including deaths) for the periodX100
total # of c-sections performed in a period/total # of deliveries in the period (including C-sections)X100
pts present at midnight or the census taking time
add admissions subtract discharges
daily inpatient census
pts present at midnight plus and pts admitted & discharge that same day
average daily cencus
Average number of inpatients, excluding newborns, receiving care each day during the reporting period
inpatient service days
is a unit of measure that denotes the services recieved by an impatient in a 24 hr period
bed occupance ratios
# of inpatient service days/ by # of days/ bed countX100
timeliness rate for discharge summaries
137/150X100 = 91.3%
# of new cases/population
IR=(number of injuries and illnesses x 200)/(number of employee hours worked)
A formal document that describes the events surrounding a surgical procedure or operation and identifies the principal participants in the surgery - don't get mixed up with anesthesia report
is necessary to locate paper health records for all types of filing systems except - alphabetical
Systematized Nomenclature of Medicine
Which of the following coding systems is a nomenclature?
Standardized vocabulary needed to facilitate indexing, storage, retrieval of patient information in the EHR
primary purpose of minum data set
recommend common data elements to be collected in health records
Structured Query Language
What language below is used to view and manipulate data that is stored in a relational database?
____ allows a user to insert, update, delete, and query data from a database:
Medicare severity-adjusted diagnosis-related groups system; a patient classification system used in hospital inpatient reimbursement
A code used to encompass all charges related to a procedure into one charge.
MS-DRG triples, pairs & singles
reason for charges in hospital medicare case mix index over time
secondary data source
Data taken from the health record and entered into registries and databases are considered a(n) _____________________.
Data extracted from individual health records and combined to form de-identified information about groups of patients that can be compared and analyzed
Data that are collected on large populations of individuals and stored in databases are referred to as ___.
You are the director of HIM at the hospital. One of your physicians has asked you for the total number of appendectomies that he performed at your hospital last year. You will provide the physician with ___ ____.
Which of the following is a risk of copying & pasting
coping note into the wrong pts record
key characteristics of a problem oriented health record
uses an itemized list of pts past and present health problems
which must be included in a pts health record prior to perfoming a surgical procedure?
consent for operative procedure, history, physical exam
in long term care, the resident care plan is based on
data collected in the MDS minium data set
secondary purpose of the health record
to provide support to research
HIT is responcible for designing a data collection form to collect data on pts in acute care hospitals
the first resource used is UHDDS
the home health prospective payment system uses what?
OASIS - C data set
random sample of 200 pts health records to determine the timeliness of the history & physicals completion - 9 records found out of compliance within the 24 hr peroid
191/200X100 = 95.5%
which describes data comprehensiveness?
data include all required elements
in addition to case mix, this factor may influence episode related data quality
length of inpatient stay
be sure to select for procedure code
Medicare Provider Analysis and Review
Medicare Provider Analysis and Review (MEDPAR) A collection of data form reimbursement claims submitted to the Medicare program by acute care hospitals and skilled nursing facilities that is used to evaluate the quality and effectiveness of the care provided
Which of the following is made up of claims data from Medicare claims submitted by acute care hospitals and skilled nursing facilities
in designing an EHR best source to help define content of record and standarized data defs. are standards promulgated by the
American Society for testing and measurement
which rate describes the probability or risk of illness in a population over a period of time?
managing organization data of who enters- what can used to help
displays # of deaths due to breast cancer from 2005-2015
a numerical measurement carried out to the appropiate decimal place
cost for mislfiles is 200$ per file (7% per 10,000) calculate
accession # is
the # assigned to each case as it is entered into a cancer registry
be sure to chose diagnosis codes for operation indexes
the paper based health record format that oranizes all forms in chronological order is known as?
integrated heatlh record
Cancer registrar are established by?
hospitals voluntary or by state law
what term is used for the # of inpatients present at any one time in a healthcare facility
intrahospital morbidity data is an ex. of data collected by the Joint Commission for the ORYX initiatives
uses the pt health record as a data source
National Ambulatory Medical Care Survey
best solution for hosp to ensure that all data needed for pt are rerieved when needed
doc scanning system for paper records and interfaced with data created in EHR with the doc scanning system
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