How can we help?

You can also find more resources in our Help Center.

104 terms

RHIT Study - Domain 1 - MXW

Updated 5/21/2013
Data sets serve two purposes?
First is to identify data elements to be collected about each patient. Second is to provide uniform data definitions?
Uniform Ambulatory Care Data Set (UACDS)
A data set designed by the National Committee on Vital and Health Statics consisting of a minimum set of patient/client specific data elements to be collected n ambulatory care settings
Uniform Hospital Discharge Data Set (UHDDS)
A core set of data elements adopted by the US Department of Health, Education, and Welfare in 1974 that are collected by hospitals on all discharges and all discharge abstract system
Data Elements for Emergency Department Systems (DEEDS) - A data set designed to support the uniform collection of information in hospital-based emergency departments
Outcomes and Assessment Information Set (OASIS) - A standard core assessment data tool developed to measure the outcomes of adult patients receiving home health services under the Medicare and Medicaid programs
Minimum Data Set - A federally mandated standard assessment form that Medicare and/or Medicaid-certified nursing facilities must use to collect demographic and clinical data on nursing home residents
A Joint Commission on Accreditation of Healthcare Organizations initiative that supports the integration of outcomes data and other performance measurement data into the accreditation process
Middle digit filing system
A numeric filing system in which the middle digits are used as the finding aid to organize the filling system (36-45-99; 37-45-99; 38-45-99)
Terminal-digit filing
A system of health record identification and filing in which the last digit or group of digits (terminal digits) in the health record number determines file placement (70-41-00; 43-42-00; 64-55-00; 52-43-01)
Unit numbering system
A health record identification system in which the patient receives a unique medial record number at the time of the first encounter that is used for all subsequent services (0001, 0002, 0003)
Serial numbering system
A type of health record identification and filing system in which patients are assigned a different but unique numerical identifier for every admission
Serial-unit numbering system
A health record identification system in which patient numbers are assigned in a serial manner but records are brought forward and filed under the last number assigned.
Unit numbering system
A health record identification system in which the patient receives a unique medial record number at the time of the first encounter that is used for all subsequent services. Information is linked to together. One advantage to this method is that all information, regardless of the number of encounters, can be filed or linked together.
Minimum Data Set for Long-term Care Version 2.0 (MDS 2.0)
The instrument specified by the Centers for Medicare and Medicaid Services 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
Prospective payment system (PPS)
A type of reimbursement system that is based on preset payment levels rather than actual changes 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.
Data accessibility
Means that the data is easily obtainable.
Data accuracy
Data is correct
Data comprehensiveness
All the required data elements are included in the health record. In essence, comprehensiveness means that the record is complete.
Data consistency
Data is reliable
Data currency
Healthcare data should be up-to-date and recorded at or near the time of the even or observation.
Data definition
Data and information document in the health record are defined.
Data granularity
Requires that the attributes and values of data be defined at the correct level or detail for the intended use of the data. (Example, numerical values for laboratory results should be recorded to the appropriate decimal place as required for the meaningful interpretation of test results - or in the collection of demographic data, data elements should be defined appropriately to determine the difference in outcomes of care amount various populations
Data precision
The term used to describe expected data values. As part of data definition, the acceptable values or value ranges for each data element must be defined.
Data quality management
A managerial process that ensures the integrity (accuracy and completeness) of an organization's data during data collection, application, warehousing, and analysis
Data relevancy
Means that the data in the health record is useful. The reason for collecting the data element must be clear to ensure the relevancy of the data collected. (Example, nursing documentation can be lengthy and physicians and other caregivers may not have sufficient time to review it.)
Data Timeliness
An essential characteristic of data quality is the timeliness of documentation or data entry.
Continuity of care document (CCD)
In the exchange of information with other providers and the patient, the CCD combines the content that physicians have agreed should be included in patients referrals with a means to format that data for electronic transmission. A core data set developed by ASTM to communicate a patient's past and current health information as the patient transitions from one care setting to another.
Continuity of care record (CCR)
Documentation of care delivery from one healthcare experience to another
Source-oriented health record
A system of health record organization in which information is arranged according to the patient care department that provided that care
Problem-oriented health record
Patient record in which clinical problems are defined and documented individually. Each progress note is labeled with the unique number assigned to the problem being addressed. Some providers also use a SOAP format for their problem-oriented progress notes. Subjective (S) Entry is significant information in the patient's words or from the patient's point of view; O = Objective (O) data includes factual information such as laboratory finings or provider observations; Assessment (A) is professional conclusion reached from evaluation of the subjective or objective information; Plans (P) aware any comments on or changes in plans.
What is the order of a problem oriented health record
Better suited to service the patient and the end user of the patient information. The key characteristic of this format is an itemized list of patient's past and present social psychological, and medical problems. Each problem is indexed with a unique number
Integrated health record format
Documentation form various sources are integrated and arranged in strict chronological order.
Systematized Nomenclature of Medicine Clinical Terminology
A concept-based terminology consisting of more than 110,000 concepts with linkages to more than 180,000 terms with unique computer-readable codes. A standardized vocabulary for facilitating the development of computer-based patient records. In numerical order
Bar graph
A graphic technique used to display frequency distribution of nominal or ordinal data that fall into categories
Check sheet
A tool that permits the systematic recording of observations of a particular phenomenon so that trends or patterns can be identified.
Fishbone diagram
A performance improvement tool used to identify or classify the root causes of a problem or condition and to display the root causes graphically. Also called cause-and-effect diagram. An investigational technique that facilitates the identification of the various factors that contribute to a problem.
Flow charts
A graphic tool that uses standard symbols to visually display detailed information, including time and distance, of the sequential flow of work of an individual or a product as it progresses through a process
Force-field analysis
A performance improvement tool used to identify specific drivers of, and barriers to, an organizational change so that positive factors can be reinforced and negative factors reduced.
A graphic technique used to display the frequency distribution of continuous data (internal or ratio data) as either numbers or percentages in a series of bars
Parieto chart
A bar graph that includes bars arranged in order of descending size to show decisions on the prioritization of issues, problems, or solutions.
Scatter diagrams"
A graph that visually displays the linear relationships among factors. Used to plot the points for two variables that may be related to each other in some way.
Anesthesia report
The report that notes any preoperative medication and response to it, the anesthesia administered with dose and method of administration, the duration of the administration, the patient's vital signs while under anesthesia, and any additional products given the patient during a procedure
Autopsy report
Written documentation of the findings from a postmortem pathological examination
Consultation report
Health record documentation that describes the findings and recommendations of consulting physicians
Discharge summary
A summary of the resident's stay at the long-term care facility that is used along with the post discharge plan of care to provide continuity of care for the resident upon discharge from the facility. The attending physician is responsible for this.
Operative report
A formal document that describes the events surrounding a surgical procedure or operation and identifies the principal participants in the surgery
Pathology report
A type of health record or documentation that describes the results of a microscopic and macroscopic evaluation of a specimen removed or expelled during a surgical procedure
Physical examination report
Documentation of a physician's assessment of patient's body systems
Recovery room report
A type of health record documentation used by nurses to document the patients reaction to anesthesia and condition after surgery; also called recovery room record
Transfer record
A review of the patient's acute stay along with current status, discharge and transfer orders, and any additional instructions that accompanies the patient when he or she is transferred to another facility; also called a referral form
Head, eyes, ears, nose, throat
Purpose of the health Record
1) Primary purpose is to facilitate quality patient care; Secondary is to Support research
American Society for Testing and Materials (ASTM)
The national organizations whose purpose is to establish standards on materials, products, systems, and services. In designing an electrical health record, one of the best resources to use in helping to define the content of the record as well as to standardize data definitions are standards promulgated.
Data element
An individual fact or measurement that is the smallest unique subset of a database
Data set
A list of recommended data elements with uniform definitions that are relevant for a particular use
The individual who initiates a lawsuit to enforce either his or her rights and/or another's obligations
The individual or organization that is the object of the lawsuit, and against whom a lawsuit is brought
Case definition
A method of determining criteria for cases that should be included in a registry
Case finding
A method of identifying patients who have been seen and/or treated in a healthcare facility for the particular disease or condition of interest to the registry
National Hospital Discharge Survey
Either abstracted manually from a sample of acute care discharged inpatient records or obtained from state or other discharge databases. Items collected follow the UHDDS including demographic data, admission and discharge dates, and finally diagnoses and procedures
National Ambulatory Medical Care Survey
Includes data collected by a sample of office-based physicians and their staffs from the health records of patients seen in one-week reporting period. Data included are demographic data, the patient's reason fro visit, the diagnoses, diagnostic/screening services, therapeutic and preventive services, ambulatory surgical procedures and medication/s injections, in addition to information on visit disposition and time spent with the physician.
National Survey of Ambulatory Surgery
Collected on representative sample of hospital-based and freestanding ambulatory surgery centers. Include patient demographic characteristics, source of payment and information on anesthesia given, the diagnose, and the surgical and nonsurgical procedures on patient visits of hospital-based and freestanding ambulatory surgery centers.
Disease index
A list of diseases and conditions of patients sequenced according to the code numbers of the classification system in use
Operation index
A list of the operations and surgical procedures performed in a healthcare facility that is sequenced according to the code numbers of the classification system in use
Physician index
A list of patients and their physicians that is usually arranged according to the physician code numbers assigned by the healthcare facility
Aggregate Data
Data extracted from individual health records and combined to form de-identified information about groups of patients that can be compared and analyzed
Primary data source
A record developed by healthcare professionals in the process of providing patient care
Secondary data source
Data derived from the primary patient record, such as an index or a database
A calculation found by dividing one quantity by another. A general term that can include a number of specific measures such as proportion, percentage and rate
The relation of one part to another or to the whole with respect to magnitude, quantity, or degree (Example - Six males and 14 females in a class of 20 students. The data reported as 3/1)
A measure used to compare an event over time: a
Middle number : The median of odd number is center number 3 (1,2,3,4,5); The median of even number is 2.5.
A measure of central tendency that consists of the most frequent observation in a frequency distribution (Example - Number 47, 20, 11, 33, 30, 30, 35 and 500. The mode is 30)
Distance or extent between possible extremes (Example - The lowest value is 5 and the highest value is 20 which makes the range 5 to 20)
Same as average = total sum of all values/number of values involved. A measure of central tendency that is determined by calculating the arithmetic average of the observations in a frequency distribution (Example - The mean of 10, 15, 20, 25, and 25 is 19)
Average Daily Census
The mean number of hospital inpatients present in the hospital each day for a given period of time (Total service days for the unit for the period/Total number of days in the period)
Average Length of Stay (ALOS)
The mean length of stay for hospital inpatients discharged during a given period of time.(Total length of stay (discharge days)/Total discharges (includes deaths)
Percentage of Occupancy
The total number of inpatient service days for a given time period divided by the total number of inpatient bed count days for the same period; also called percentage of occupancy ((Total service days for a period/Total bed count days in the period)X100)
Hospital Death Rate (Gross)
((Number of deaths of inpatients in period/Number of discharges (including deaths))X100)
Gross Autopsy Rate
The number of inpatient autopsies conducted during a given time period divided y the total number of inpatient deaths for the same time period. ((Total inpatient autopsies for a given period/Total inpatient deaths for the period)x100)
Net Autopsy Rate
The ration of inpatient autopsies compared to inpatient death calculated by dividing the total number of inpatient autopsies performed by the hospital pathologists for a given time period by the total number of inpatient deaths minus un-autopsied coroners, or medical examiners cases for the same period((Total inpatients for a given period/(Total inpatient deaths - un-autopsied coroners or medical examiners cases))X100)
Hospital Death Rate (Adjusted)
The number of inpatient deaths for a given period of time divided by the total number of live discharges and deaths for the same time period. ((Total hospital autopsies/Number of deaths of hospital patients whose bodies are available for hospital autopsy)X100 )
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 time((Total number of intermediate and/or late fetal deaths for a period/(Total number of live births + intermediate and late fetal deaths for the period))X 100)
Neonatal Mortality Rate (Death Rate)
The number of deaths of infants under twenty-eight days of age during a given time period divided by the total number of births for the same time period((Total number of newborn deaths for a period/Total number of newborn infant discharges (including deaths) for the period) x 100)
Maternal Mortality Rate (Death Rate)
For a hospital, the total number of maternal deaths directly related to pregnancy for a given time period divided by the tota number of obstetrical discharges for the same time period; for a community, the total number of deaths attributed to maternal conditions during a given time period in a specific geographic area divided by the total number of live births for the same time period in the same area. ((Total number of direct maternal deaths for a period/Total number of obstetrical discharges (including deaths) for the period)X 100)
Cesarean-Section Rate
The ratio of all Cesarean sections to the total number of deliveries, including Cesarean sections, during a specified period of time. ((Total number of Cesarean sections performed in a period/Total number of deliveries in the period (including Cesarean sections)X 100)
Prevalence Rate
The proportion of persons in a population who have a particular disease at a specific point in time or over a specified period of time (All new and pre-existing cases of a specific disease during a given time period/Total population during the same time period)X10
Incidence Rate
Used to compare the frequency of disease in different populations. Populations are compared using rates instead of raw number because rates adjust for differences in population size. (Total number of new cases of a specific disease during a given time period/Total population at risk during the same time period) X 10
Daily Inpatient Census
The number of inpatients present at census-taking time each day, plus any inpatients who were both admitted and discharged after the census-taking time the previous day
Length of Stay (LOS)
The total number of patient days for an inpatient episode, calculated by subtracting the date of admission from the ate of discharge
Which rate is used to compare the number of inpatient deaths to the total number of inpatient deaths and discharges?
Gross hospital death rate (The gross hospital death rate is the proportion of all hospital discharges that ended in death. It is the basic indicator of mortality in a healthcare facility. The gross death rate is calculated by dividing the total number of deaths occurring in a given time period by the total number of discharges, including deaths, for the same time prior
Which unit of measure is used to indicate the services received by one inpatient in a 24-hour period?
Inpatient service days (Number of inpatient service days for a 24 hour period is equal to the daily inpatient census, that is, one service day for each patient treated.
Which term is used to describe the number of calendar days that a patient is hospitalized?
Length of stay (LOS) is calculated for each patient after he or she is discharged form the hospital. It is the number of calendar days from the day of patient admission to the day of discharge.
In analyzing the reason for changes in hospital's Medicare case-mix index over time, the analyst should start with which of the following levels of detail?
MS-DRG triples, pairs, and singles (Some case-mix systems use the CMI as a basis for reimbursement. In that way, the CMI also is a measure of the average revenue received per case. Many hospitals closely monitor the movement of their CMI for inpatient populations for which payment is based on the DRG and for outpatient populations for which payment is based on APC
Which of the following use data from the MDS for long-term care
Centers for Medicare and Medicaid Services
Prevalent trend in the collection of secondary databases is:
Increased use of automated data entry (Although registries and databases are almost universally computerized, data collection is commonly done manually, not all data collection is done manually. In some cases, data can be downloaded directly from other electronic systems. As the electronic health record (EHR) develops further less and less data will need to be manually abstracted since it will be available electronically through the EHR)
Which of the following is a database form the National Health Care Survey that uses the patient health record as a data source?
National Ambulatory Medical Care Survey (Data for National Survey of Ambulatory Surgery are collected on a representative sample of hospital-based and freestanding ambulatory surgery centers. Data include patient demographic characteristics, source of payment; information on anesthesia given, the diagnoses and the surgical and nonsurgical procedures on patient visits of hospital-based and freestanding ambulatory surgery centers
Comprehensiveness also referred to as completeness is another factor. Missing data may prevent the database from being useful for research or clinical decision making.
Data accuracy, also referred to as data validity means that data is correct. (Example Cancer registry, the stage of the neoplasm must be recorded accurately because statistical information on survival rates by stage is commonly reported)
Consistency is sometimes referred to as data reliability.
Means that healthcare data should be up-to-date. Data must also be available within a time frame helpful to the user.
Characteristics of the common healthcare data set such as UHDDS and UACDS
They define minimum data elements to be collected; They provide a framework for data collection to which an individual facility can add data items; The federal government recommends, but does not mandate, implementation of most of the data sets
Information standards that provide clear descriptors of data elements to be included in computer-based patient record systems are called
Structure and content
What is the Format for their problem-oriented progress notes
SOAP Subjective (S); Objective (O); Assessment (A) Plans (P) •Subjective information (What is the patient telling you?) •Objective information (What are your observations and tools telling you?) •Assessment of the patient (What do you think is happening?) •Plan of action (What are you going to do about it?)