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RHIT Prep Domain 1: Data Analysis and Management
Text used "Registered Health Information Technician Exam Preparation" by Darcy Carter
Terms in this set (105)
After cases have been identified, extensive information is _____ from the pt's paper-based health records into the registry database or extracted from other databases & automatically entered into the registry database.
case mix index
The average relative weight of all cases treated at a given facility or by a given physician which reflects the resource intensity or clinical severity of a specific group in relation to the other groups in the classification system: Sum of the # of cases in each DRG X weight for that DRG / Total Cases
MPI: Master Patient Index
a list or database created and maintained by a healthcare facility to record the name and identification number of every pt who has ever been admitted or treated in the facility. While not listed as one of the core elements of an _____, AHIMA recommends the use of a Unique Patient Identifier to be included in the core data elements of the _____.
A critical early step in designing an EHR is to develop a(n) _____ in which the characteristics of each data element are defined.
One hospital discharge abstract systems were developed and their ability to provide comparative data to hospitals was established, it became necessary to develop:
Two purposes are served by _____: to identify data elements to be collected about each pt & provide uniform data definitions.
UHDDS: Uniform Hospital Discharge Data Set
The first resource that an HIT should consult when designing a data collection form to collect data on pts in an acute-care hospital is:
UHDDS: Uniform Hospital Discharge Data Set
The purpose of the _____ is to list and define a set of common, uniform data elements. The data elements are collected from the health records of every hospital inpt and later abstracted from the health record and included in national databases.
A _____ is a list of recommended data elements with uniform definitions that are relevant for a particular use. the contents of _____ vary by their purpose & are not meant to limit the number of data elements that can be collected.
When deficiencies in the health record, such as reports that need to be dictated or signed by a physician or other health professional, are identified through ____ analysis, the record is filed in a specially designated area of the HIM department, frequently called the incomplete file room.
In a paper-based system, the completion of the chart is monitored in a special area of the HIM department called the _____ file room.
filing system in which the pt receives a unique health record number at the time of the first encounter. For all subsequent encounters for a particular pt, the health record number that was assigned for the first encounter is used
alphabetic filing system
The following are disadvantages of _____:
Does not ensure a unique identifier.
Does not expand evenly.
Time consuming to purge or clean out files for inactive storage.
alphabetic filing system
This system is usually satisfactory for a very small volume of records like that of a small physician practice.
a _____ is a request from a clinical or other area in the organization to charge out a specific health record. It may be in paper or electronic form.
elements of a requisition
Usually includes the pt's name, health record number, date of the request, date and time needed, name of the requester, and location for delivery.
MS-DRG triples, pairs, and singles
In analyzing the reason for changes in hospital's Medicare case-mix index over time, the analyst should start with which level of detail?
The _____ is the most common type of tracking system used to track paper-based health records. It is usually made of strong colored vinyl with two plastic pockets and is the size of a regular record folder and is place in the record location when the record is removed from the file.
confidentiality, integrity, and availability
The goals of the HIPAA security rule are to ensure the _____, _____, and _____ of the ePHI.
_____ is ensuring that data are not altered either during transmission across a network or during storage.
_____ system is considered to be the most efficient. The last group of digits is the primary unit used for filing, followed by the middle unit and lastly the first unit.
Minimum data set
The primary purpose of a ____ in healthcare is to recommend common data elements to be collected in health records.
MDS: Minimum data set
In long-term care, the resident's care plan is based on data collected in the _____. The data collected by the _____ are used to develop a resident assessment protocol (RAP) summary for each resident. The _____ provides a structured way to organize resident information and develop a resident care plan.
Tasks that need to be performed in a specific sequence
Incorporating a workflow function in an electronic information system would help support:
A ____ is a special type of database that consolidates and stores data from various databases throughout an enterprise/organization. _____ are designed to perform data analysis rather than to support routine operation.
Core data elements
Each of the 3 dimensions (personal, provider, and community) of information defined by the NHIN contains specific recommendations for:
Continuity of care record
A core data set developed by ASTM to communicate a pt's past and current health information as the pt transitions from one care setting to another is:
The home health PPS uses the _____ data set for pt assessments.
OASIS: Outcomes and Assessment Information Set
_____ is a standardized data set designed to gather data about Medicare beneficiaries who are receiving services from a home health agency. _____ includes a set of core data items that are collected on all adult home health pts.
HEDIS: Health Plan Employer Data Information Set
_____ is sponsored by the NCQA. _____is a set of standard performance measures designed to provide healthcare purchasers and consumers with the information they need to compare the performance of managed healthcare plans.
NCQA: National Committee for Quality Assurance
not for profit organization dedicated to assessing and reporting on quality and performance of health care plans; accredits HMO's
The data set designed to organize data for public release about the outcomes of care is:
_____ allows a user to insert, update, delete, and query data from a database.
The purpose of a _____ is to store and retrieve data.
SQL: Structured Query Language
A popular common language called _____ is used to store and retrieve data in relational databases. _____ gives the information system the ability to query and report on data and to insert, update, and delete data from the database.
MPI: Master Patient Index
The _____ is the permanent record of every pt ever seen in a healthcare facility. The amount of information contained on each PT in the _____ varies from facility to facility. However, the basic info usually includes: PT's last, first & middle names, their DOB, gender and dates of encounter. Can also include additional information such as address, phone #, and attending physician for each encounter or other pt identifiable information.
A(n) _____ entry in an a SOAP note relates significant information in the pt's words or from the pt's point of view. Ex: "Occasionally gets hungry. No insulin reactions. Says she is following her diabetic diet."
A(n) _____ entry in an a SOAP note relates observations about the patient, such as physical findings or lab or X-ray results.
A(n) _____ entry in a SOAP note relates professional conclusions reached from evaluation of the other information gathered during the encounter. Ex: "Blood pressure adequately controlled."
A(n) _____ entry in an a SOAP note relates diagnostic, therapeutic, and educational plans to resolve the problem.
SNOMED: Systemized Nomenclature of Medicine Clinical Terminology
a comprehensive clinical vocabulary designed to encompass all the terms used in medicine, including procedures and diagnoses. provides the most comprehensive controlled vocabulary for coding the content of a pt record which facilitates the development of computer-based pt records.
Provides a system for classifying morbidity and mortality information for statistical purposes.
_____ represents basic facts, while _____ represents meaning.
Structure and content
Information standards that provide clear descriptors of data elements to be included in computer-based pt record systems are called _____ standards.
data currency / timeliness
_____ means that healthcare data should be up-to-date and recorded at or near the time of the event or observation.
_____ means that the data is reliable. Reliable data do not change no matter how many times or in how many ways they are stored, processed or displayed.
A _____ is used to plot the points for two continuous variables that may be related to each other in some way. Ex: Age & blood pressure; one would be plotted on the x-axis and the other on the y-axis
Data quality model
_____ applies the following quality characteristics: data accuracy, data accessibility, data comprehensiveness, data consistency, data currency, data definition, data granularity, data precision, data relevancy, and data timeliness.
_____ requires that the attributes and values of data be defined at the correct level of detail for the intended use of the data. Ex: numerical measurement carried out to the appropriate decimal place
Pt care delivery, pt care management, pt care support processes, financial & other administrative processes and pt self management are all ____(s) of the health record.
_____ means that all the required data elements are included in the health record (the record is complete).
_____ means that the data are easily obtainable.
_____ is the unit/department in which the health record number is typically assigned.
The _____ report describes the surgical procedures performed on the pt.
The _____ report includes tests performed on blood, urine, and other samples from the pt.
The _____ is a concise account of the pt's illness, course of Tx, response to Tx, and condition at the time the pt is dicharged from the hospital. Also includes follow-up care instructions & provides an overview of the entire medical encounter. It is the responsibility of, and must be signed by, the attending physician.
_____ maintain chronological records of the pt's vital signs & separate logs that show what medications were ordered and when they were administered.
_____ data document the pt's medical condition, Dx, and procedures performed as well aas the healthcare Tx provided.
_____ data include demographic and financial information as well as various consents and authorizations related to the provision of care and the handling of confidential pt info.
The following is documented in an acute-care record: "Atrial fibrillation with rapid ventricular response, left axis deviation, left bundle branch block." In what type of report would this documentation appear?
Social Services Note
The following is documented in an acute-care record: "Spoke to the attending re: my assessment. Provided adoption and counseling information. Spoke to CPS re: referral. Case manager to meet w/ pt & family." In what type of documentation would this appear?
Patient's instructions at discharge, time & means of pt's arrival, care administered before arrival at the facility & clinical observations are all likely to be included in the pt's health record for an _____ visit, though the pt's complete medical history would not.
The _____ health record is better suited to serve the pt & the end user of the pt info. The key characteristic of this format is an itemized list of the pt's past & present social, psychological, & medical problems. Each problem is indexed with a unique number & are organized in numerical order. Consists of 4 components: database, problem list, initial plan & progress notes.
In a problem-oriented health record, problem are organized in ____ order
A traditional patient record format known as the _____ maintains reports according to source of documentation. Ex: documentation generated by nursing staff would be located in the nursing section of the record.
Advantages: Files same source docs together; Easy to locate information from same source.
Disadvantages: Difficult to follow one diagnosis; Create many sections in record; Filing reports is time consuming
Advantages: Links all documentation to a specific problem; Facilitates patient treatment and education.
Disadvantages: Requires training; Filing of reports is time consuming; Data associated w/ more than 1 problem must be documented several times.
Advantages: Provides high degree of organization; Easy to use; All info on an episode of care is filed together; Less time-consuming to file reports.
Disadvantages: Difficult to compare & retrieve info from same discipline
The _____ format usually arranges reports in strict chronological order. This format allows for observation of how the pt is progressing & is responding to treatment.
The _____ documents the clinical opinion of a physician other than the primary or attending physician.
records that document pt care provided by healthcare professionals and include original pt record, X-rays, scans, EKGs & other documents of clinical findings.
pt info that contains data abstracted (selected) from the original pt record, X-rays, scans, EKGs & other documents of clinical findings such as indexes & registers, committee minutes, & incident reports. Sometimes referred to as "aggregate" data.
Examples of _____ purposes of the health record are support for research, to serve as evidence in litigation, to allocate resources, and to plan market strategy.
Patient care management refers to all the activities related to managing the healthcare services provided to patients and is a _____ purpose of the health record.
ASTM: American Society for Testing and Materials
_____ is an international standards organization that develops and publishes voluntary consensus technical standards for a wide range of materials, products, systems, and services. The _____ Technical Committee on Health Informatics E31 is charged with the responsibility for developing standards related to the EHR.
_____ is a standards development organization accredited by the American National Standards Institute that addresses issues at the application level of healthcare systems interconnections. It develops messaging, data content, and document standards to support the exchange of clinical information.
Using a hospital discharge database, a physician does a study of diabetes mellitus comparing age of onset w/ response to a specific drug regimen. They physician has gathered _____ from the database.
The stability, repeatability, or precision of data
Characteristics for data entry should be uniform throughout the pt record to ensure _____.
_____ is a term referring to the incidence of death in a specific population or the loss of subjects during the course of a clinical research study.
The _____ is a listing in diagnosis code number order for patients discharged from the facility during a particular time period. Each pt's diagnoses are converted from a verbal description to a numerical code, usually using the ICD. The pt's Dx codes are entered itno the facility's health info system as part of the discharge processing of the patient's health record.
The _____ contains a list maintained in procedure code number order for pts discharged from a facility during a particular time period.
_____ s a method used to identify the pts who have been seen and/or treated in the facility for the particular disease or condition of interest to the registry.
In a cancer registry, the _____ is the number assigned to each case as it is entered into a cancer registry.
_____ include data on births, deaths, fetal deaths, marriages & divorces. Responsibility for the collection of _____ rests w/ the states.
secondary data that include data on groups of people or pts w/out identifying any particular pt individually. Ex: ALOS statistics for pts discharged w/ a particular DRG
A _____ is a type of ratio in which
is a portion of the whole
. In a _____ the numerator is always included in the denominator.
The _____ is the simplest measure of spread. It is the difference between the smallest and largest values in a frequency distribution.
A hospital _____ is a person who is provided room, board, and continuous general nursing service in an area of the hospital where patients generally stay at least overnight.
A hospital _____ is a hospital patient who receives services in one or more of the outpt facilities when not currently an inpt or a home care pt.
_____ is a measure of central tendency that consists of the most frequent observation in a frequency distribution.
A measure of central tendency that shows the midpoint of a frequency distribution when the observations have been arranged in order from lowest to highest.
gross autopsy rate
If you want to display the parts of a whole in graphic form, what graphic technique would you use?
A(n) _____ is used to compare the frequency of disease in different populations.
daily inpatient census
The result of the official count taken at midnight is the _____. This is the number of inpatients present at the official census-taking time each day plus any patients who were admitted and discharged after the census taking time the previous day.
LOS: Length of Stay
is calculated fore each patient after he/she is discharged. It is the number of calendar days from the day of pt admission to the day of discharge.
inpatient service day
A unit of measure that reflects the services received by one inpatient during a 24-hour period is a(n) _____.
gross hospital death rate
the rate that is used to compare the number of inpt deaths to the total number of inpt deaths and discharges
gross autopsy rate
A(n) _____ is the proportion or percentage of deaths that are followed by the performance of autopsy.
term used for the number of inpts present at any one time in a healthcare facility
daily inpatient census
the result of the official count taken at midnight is the _____
OBRA required _____ to develop an assessment instrument to standardize the collection of SNF (skilled nursing facility) patient data. That instrument is known as the RAI (resident assessment instrument) and includes the MDS (minimum data set).
A _____ is a research project in which new treatments and tests are investigated to determine whether they are safe and effective.
Case Mix Index
The capture of secondary diagnoses that increase the incidence of CCs and MCCs at final coding may have an impact on _____
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