193 terms


What is the goal of clinical practice guidelines?
to standardize clinical decision making
What is the largest healthcare standards-setting body in the
True or False: A responsibility of a healthcare organization's quality management department is using medical peer review to identify patterns of care
It is a set of processes used to determine the appropriateness of medical services provided during specific episodes of care
utilization managment
True or False: Documentation utilization review is a type of utilization review
Coordinates medical care and ensure the necessity of the services provided to beneficiaries
case manager
A hospitals C-section rate is an example of a ___ ____ ___.
clinical performance measure
The process that involves ongoing surveillance and prevention of infections so as
to ensure the quality and safety of healthcare for patients and employees is known
infection control
True or False: Data collected during the process of providing patient services are the best source
of information on the effectiveness of care.
True or False: The 1999 through 2004 reports issued by the Institute of Medicine determined
that premature discharge of inpatients from U.S. hospitals was the main reason
for less than optimum quality healthcare.
True or False: The National Committee on Quality Assurance (NCQA) has issued specific
national patient safety goals in response to its identification of patient safety as its
top priority in accrediting managed healthcare organizations.
True or False: JCAHO's methodology for accessing quality of healthcare during its survey
process is to follow specific patients through their entire admission and to identify
non-compliance with standards as reflected in the experience of patients.
True or False: Clinical practice guidelines are developed with the goal of standardizing clinical
decision and therefore must be followed in every case.
True or False: The National Guideline Clearinghouse (NGC) issues clinical guidelines that are
mandated by the federal government.
True or False: Thanks to technology and scientific advances, infection has disappeared in the
beginning of the 21st century as a significant problem impacting healthcare.
True or False: NCQA has loose standards for managing utilization of healthcare resources but
very rigorous standards for managing quality and reimbursement.
True or False: Because of their importance to patient care, incident reports are always filed in
the patient's medical record.
True or False: One of the JCAHO's national patient safety goals in the area of communications
requires healthcare organizations to implement a JCAHO defined list of
unacceptable medical abbreviations to be used in the patient's medical record.
is a methodology for assessing compliance with JCAHO
standards during the survey process.
tracer methodology
are contracted to the federal government to use medical peer review, data
analysis, and other tools to identify patterns of care and outcomes that need
improvement and then to work cooperatively with facilities and individual
physicians to improve care.
refers to initiatives and programs that reward organizations
and providers for quality outcomes.
pay for performance
refers to computerized systems into which physicians or hospital staff
directly enter medication orders and therefore benefit from immediate alerts and
pharmaceutical information in order to reduce the frequency of medication errors.
are JCAHO standards for improving patient safety.
The traditional approach to assuring quality was to view quality as the _____ __ ___.
absence of defects
Total quality management and continuous quality improvement are well-known
_____ ___ ___.
performance improvement models
Donabedian proposed three types of quality indicators: structure indicators,process indicators, and _____ ____.
outcome indicators
Problems in patient care and other areas of the healthcare organization are usually
symptoms inherent in a ____.
Many organizations and quality experts define quality as meeting or exceeding _____ _____.
customer expectation
The work of performance improvement is accomplished through _____.
Teams generally go through the following stages as they develop: forming, __,
norming, and performing.
The man credited with revitalizing the Japanese economy after World War Two
was _____.
The individual whose principal responsibility is to facilitate the process of change
is the _____ ____.
change agent
Peter Senge believed that each individual within an organization must be committed to personal mastery and must always seek to _____.
The steps in Langley, Nolan, and Nolan's PDSA cycle are _____.
plan, do, study, act
Brainstorming, affinity grouping, and nominal group technique are tools and techniques used during performance improvement initiatives to facilitate _____ among employees.
Which of the following terms refers to the process of planning for change?
change management
Which of the following is a technique used to generate a large number of creative ideas
from a group?
Which of the following is a data collection tool that records and compiles
observations or occurrences?
Which of the following is used to plot the points for two variables that may be related to each other in some way?
scatter diagram
The leader of the coding performance improvement team wants all of her team members
to clearly understand the coding process. Which of the following would be the best tool
for accomplishing this objective?
flow chart
The medical transcription improvement team wants to identify the cause of poor
transcription quality. Which of the following tools would best aid the team in
identifying the root cause of the problem?
fishbone diagram
According to the ____ ___, 20 percent of the sources of a problem are responsible for 80 percent of its actual effects
pareto principle
_____ ____ _____ provide a full range of healthcare services along a continuum of care to
ensure that patients get the right care at the right time from the right provider.
Integrated delivery system
A group of healthcare organizations that collectively provides a full range of coordinated health-related services is called ____ ____ ___.
integrated delivery system
Where was the first hospital organized in the British colonies of North America?
The ancient _____ developed surgical procedures, documented clinical cases,
and created medical books.
Was established to represent the interests of physicians across the country
Under which president express unreserved support for national health insurance
which legislation never passed?
Provides healthcare benefits to low income persons and their children
Individuals who receive acute care services in a hospital are considered what?
Hospitals are classified by what three characteristics?
type of services provided, type of ownership, number of beds
Describes the organizations purpose and the customers it serves
mission statement
In almost every hospital, the largest clinical department in terms of staffing,budget, specialized services offered, and clinical expertise required is which of ___ ___ __.
patient care services
The intention of managed care what to manage what three things?
cost, quality, access to care
Any surgical procedure that does not require an overnight stay in a hospital
ambulatory surgery
Why are home healthcare services the fastest growing sector of medicare?
because of increased economic pressure from third party payers
In almost every hospital, the largest clinical department in terms of staffing,
budget, specialized services offered, and clinical expertise required is which of
the following?
first world war
True or False: Both associate's and Bachelor's degree nursing graduates quality to become RNs
Today, medical school students must pass a test before they can obtain a _____ to
practice medicine.
The first general training school for _____ was opened at the New England
Hospital for Women and Children in 1872.
_____ govern(s) the operation of a hospital medical staff.
medical staff bylaws
The exchange of data among multiple software products is known as ___ ___
computer interface
A technique that uses software to search for patterns and trends and to produce data content relationships is called ___ ___
data mining
The federal agency responsible for maintaining official vial statistics is the ____
Cancer registries standards are published the the ____ , which surveys cancer registry programs in health care facilities
A portable, updatable card used to store personal data and medical history is a(n) ___ ___.
smart card
The process for translating data into information is ___ ___.
data analysis
True or False: A provider is allowed to redisclose PHI if the disclosure is for a purpose permitted by the privacy rule
True or false: An authorization is needed by a provider's attorney if the provider is involved in a medical malpractice lawsuit
Third party payers and vendors are termed business ____ under HIPAA
The type of law passed by legislative bodies is referred to as ____ law
True or false: civil suites are brought against crimes
If they feel their privacy has been violated under HIPAA, patients can complain to the Department of ____. (acronym)
True or False: The SSN is considered PHI
True or False: A covered entity must protect the PHI of deceased patients for ten years following death
A public official who investigates deaths due to unnatural causes is a ____.
The person who initiates a civil complaint is the ____.
A rule of conduct passed by a legislative body is called ___.
The ___ ___ is responsible for ensuring that privacy policies are covered
privacy officer
Which aspect of HIPAA protects health insurance coverage for workers and their families when they change or lose their jobs?
True or False: The patient owns the medical record
True or False: Incident reports are internal administrative documents
Requests to perform research studies are considered by which hospital group?
institutional review board
The time period during which a lawsuit can be filed is called the ___ __ ____
statute of limitations
Re-release of information is called ____.
The order that prohibits the use or disclosure of PHI beyond current litigation
qualified protective order
The DHHS agency that provides federal health care services to Native Americans and Alaskan Natives is the ___.
A listing of all the procedures, services, and supplies provided to hospital patients by a hospital can be found on a(n) ______.
A listing of all the procedures, services, and supplies provided to hospital patients by a hospital can be found on a(n) ______.
electronic data interchange
The federal agency established in 1977 to manage the Medicare and Medicaid programs was called the _____ (Acronym)
Who processes claims for reimbursement covered by a health care plan?
Uses thy term EHR in the development of standards for exchange of health information
In all electronic health record applications, there are two major components of the system which are _____ and ____
administrative, clinical
Raw facts that are not interpreted or processed, such as numbers, letters, images, symbols and sounds referred to as ____.
True or False: A computerized medical record has been in place since the 1960s in universities
Which patient record was introduced by the IOM in 1991?
computerized personal record
Which type of system collects and monitors patient physiological data and records the information?
patient monitoring system
The type of application that includes order entry, identification of drug interactions, medical label printing, and administrative reports such as drug usage is known as a(n) _____ _____.
pharmacy application
In February 2009, Congress enacted an act that includes an investment of $19 billion for health information technology; what is the act?
True or False: Scanning of documents can keep a facility in a paper based system
According to the ____ 1991, the health care industry's development of automated system was fast paced.
AHIMA has how many documents regarding the electronic record topics in practice brief/tools website?
AHIMA defines the ___ as a computerized record of health information associated processes.
A ____ ____ _____ includes system that allow for the continuous monitoring and collection of vital signs
patient monitoring system
IOM uses the term ____ in the development of standards for exchange of health information
After a document is finally saved, the document must not be ___.
True or False: The federal law is the primary basis for the definition of the legal patient record
An application system that includes ordering of laboratory tests, the reporting of test results, and report generation is known as a(n)_____ ____.
lab application
True or False: optical disk imaging is used to capture the paper record onto microfilm
An example of removing all fasteners from documents is called ____.
A collection of related field forms a ____.
A disadvantage of a manual record system is the difficulty to ____ information.
True or False: A patient monitoring system includes the processing of laboratory results to providers via electronic health information exchange
True or False: Amendments to a patient record as well as the original record will show in the EHR
At his State of the Union Address, President ____ supported the use of EHR to improve care
Which imaging system uses laser technology to create the image?
optical disk imaging
The ability for health care providers to access patient information that was generated at other facilities is called:
True or False: A hybrid record is electronic
The equipment used to capture paper record images onto electronic storage media is called a _____.
True or False: A group of characters forms a file
True or False: The term computerized medical records was used to describe the early medical record automation
Are considered a transitional state until a true EHR can be implemented
hybrid record
True or False: The standards for the exchange of health information are being developed by AHIMA
What was the vision of the IOM 1991 report on the computerized patient record (CPR)?
longitudinal patient record
True or False: The final diagnosis is always the same as the admitting diagnosis
True or False: The admitting diagnosis is considered demographic data
The Review of Systems (ROS) is usually found on the _____ ___ ____
According to the Joint Commission, a discharge summary is not required for patient stays less than ___ hours, unless the case becomes complicated.
A machine that imprints the patient's identification data onto each form in the medical record is called a(n) ____ ____.
addressograph machine
True or False: The copy of the birth certificate is always filed in the medical record
The patient is usually advised of his or her right to an advance directive by which hospital department?
True or False: When no other writing instrument is available, it is permissible to make medical record entries with a pencil
Which government agency developed a standard birth certificate that can be adopted for use in each state?
national center for health statistics
Which data is collected on Medicare and Medicaid patients?
True or False: The medical staff rules and regulations specify when voice orders are allowed
True or False: HIPAA requires that consent to admission be signed by each patient
True or False: A physician cannot admit patients if the physician's privileges have been suspended
True or False: The UHDDS is the minimum core data collected on ambulatory patients
The face sheet is also called _____ or ____ record
admission, discharge
Upcoding inpatient cases to maximize reimbursement is called ____ ____.
DRG creep
The Uniform Hospital Discharge Data Set (UHDDS) consists of how many data elements?
The concept of ___ ____ refers to the healthcare organization's ability to combine information from any system within the organization
systems integration
In addition to patient care, clinical information systems may be used for what three things?
peer review, research, quality improvement
Refers to the accuracy of data
Refers to consistency of data
Refers to data being available within a time frame helpful to the user
Refers to data values that are just large enough to support the application process
Can be used when a patient is readmitted for the same or related problem within 30 days
interval H&P
No matter how long the patient stays or how minor the condition, a(n) ____ is required.
MDS is designed for use in _____ facilities
Set of regulations that health care institutions must follow to receive Medicare reimbursement
A daily government newspaper for publishing proposed and final rules of federal agencies
federal register
electronic data management system
computerized provider order entry
Always the primary concern when designing new systems
needs of the end user
Primary concern in forms designed
needs of the user
A recommendation for improvement from the Joint Commission is indicated if the number of delinquent records is greater than ___ percent or if the percentage of records with delinqeunt records due to missing H&Ps exceeds __ percent of the average monthly discharges
50, 2
Mandates comprehensive functional assessments of LTC residents using the MDS for LTC
Include security levels for each field as well as definitions for all entries
data dictionary
requires a consultation report on patients who are not a good surgical risk as well as those with obscure diagnoses, patients whose physicians have doubts as to the best therapeutic measure to be taken, and patients for whom there is a question of criminal activiy
Checking for the presence or absence of necessary reports and or signatures
quantitative analysis
Involves checking for documentation consistency, such as comparing a patients pharmacy drug profile with the medication administration record
qualitative analysis
commission on accreditation or rehabilitation facilities
Independent accreditation agency for rehabilitation facilities
intended to support health information exchange within a geographic region
regional health information organization
data elements for emergency departments
Recommended data set for hospital emergency departments
Required data set for acute care hospitals
Required data set for LTC facilities
An initiative of Joint Commission whereby five core measures are implemented to improve safety and quality of health care
Typically involves quality of care issues rather than quality of documentation issues
peer review
ensures that the record entries would be acceptable in a court of law
legal analysis
Joint Commission conducts unannounced on site surveys approximately every ___ ___.
A permanent log of all the cases entered into the database
accssion register
Was signed into law in 2009 and included significant funding for HIT.
May substitute for a discharge summary
final progress notes
A final progress note may substitute a discharge summary in what three cases
patients hospitalized less than 48 hours with minor problems, normal newborns and uncomplicated obstetrical deliveries
In a POMR, the problem list includes ___, ___, ____ __ ____ and serves as a ___ __ ____.
titles, numbers, dates of problems, table of contents
In a POMR, the initial plan describes ___, ___ and ___ ___ __.
diagnostic, therapeutic, patient education plans
In a POMR, the progress notes documents the progress of a patient throughout the ___ __ ___, summarized in a ___ ___ or ___ __ at the end of stay
episode of care, discharge summary, transfer note
Program mandated to find and correct improper Medicare payments paid to health care providers participating in the Medicare reimbursement program
what two components can be captured after discharge?
signature and discharge summary
True or False: The SOAP format is required by JCAHO
Implies that data are consistent no matter how many times the same data are collected and entered into the system
data reliability
Implies that data are available to authorized people when and where needed
data accessibility
Implies that all required data are preset in the information system
data completeness
The time frame in which summaries about patient care in home health is provided to the physician is called the patient's ____ ____.
recertification period.
Recertification can continue every ___ days until the patient is discharged from home health services
Only the ___ __ is required to document the formal release of a patient from the facility
discharge order
Are reported directly to CMS and must conform to agency standards
MDS data