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As a result of HIPAA what new roles have been developed.

Security, Privacy, and Compliance officers

Electronic Health Record



A record that resides in an electronic system specifically designed to support users by providing accessibility to complete and accurate data, alerts, reminders, clinical decision support systems, links to medical knowledge and other aids.


HIM professionals are frequently involved in both the design and implementation states of an electronic health record.

What nontraditional roles may or may not involve direct patient care?


A patient is transferred to a long term care facility, what does this tell you about the patient.

The patient is no longer in need of acute care but does need continued nursing service in a facility.


is directly tied to the ability of the facility to attract patients and receive reimbursement.

Belonging to one's professional association is an important way of

finding current information and learning about changes in one's chosen field.


Refers to the delegation of health care operations from internal production of a business to an external entity that specializes in an operation.

1965 Ammended Social Security Act provided 2 government subsidized health care programs...

Medicare - persons over the age of 65
Medicaid - Persons who are poor or impoverished

Continuum of care

refers to matching an individuals ongoing needs with the appropriate level and type of care.

What has proven to be the most relevent to the development of treatments to improve or cure disease.

The connection between cause and effect.


An external entity has reviewed the program of study to determine if the program meets certain predetermined standards.

The healthcare delivery system is both

varied and complex

Ambulatory health care

A patient goes in for minor surgery and is discharged within 24 hrs, what type of care is best described by this scenario.

What is the focus of E-HIM

The electronic health data and the manner in which it is collected, validated, stored and disseminated.

In today's health care environment, the focus has changed from

records management to include data manipulation and information management.

HIM professionals working in a correctional facility would notice the greatest difference in

Increased involvement with the judicial system.

HIM professionals working in a home health care agency would need to be familiar with the data elements of the

OASIS / Outcome and Assessment Information Set used for medicare reporting.

List the three electronic health information management initiatives.

To promote the transition from a paper-based to an electronic health information infrastructure.
To reinvent the manner in which institutional and personal health information is managed.
To deliver measurable cost and quality results from improved information management.


American Health Information Management Association

Credentials awarded by AHIMA


Health Information Records

are the health care provider's legal document of patient care.

One of the main reasons for HIPAA regulations is to

combat waste, fraud, and abuse.

Record retention policies

can vary from state to state.

The privacy rule establishes

the concept of protected health information.

If a patient is scheduled for abdominal surgery, what type of consent would be required before the operation.

Informed consent

A patient requests to see his health care record, what are his rights in this scenario?

The patient has the right to access his own information.

A subpoena duces tecum is best described as

a command to produce books, documents, and other physical items.

No, this is considered physician self referal

A physician's brother owns and operates a local clinical laboratory, and has asked his brother to help him out by referring patients to him when he orders his lab work. Is this legal?

If a patient requests an accounting of disclosures made by the health care provider, the provider has _____days to act upon the request.


Identity theft is

the knowing transfer or use, without lawful authority, of the identity of another person with the intent to commit, aid, or abet any unlawful activity that constitutes a violation of federal, state, or local law.

Whistle blower

An employee notices that upcoding is being done by her department. When she reports this to the appropriate authority, she is then called a ...

Three examples of individual identifiers protected under HIPAA are:

social security numbers, dates: of birth, or admission or discharge, address and telephone numbers, email addresses, photographs, IP addresses


T/F Code of ethics are binding agreements that are written specifically for each professional area.

What does the principle of minimum necessary standard govern? What is required of the healthcare provider?

The principle of minimum necessary staindard governs the release of patient specific information. The health care provider is required to make reasonable efforts to limit the patient - specific health information disclosed to the least amount necessary to accomplish the intended purpose of the use, disclosure, or request.

Ethical dilemma

Should embryonic cells be used for research?

Living will

Document executed while patient is competent that provides direction as to medical care the patient should receive in the event they are incapacitated or unable to make personal decisions.

Behaviors showing Elements of ethics

Treats others with respect, keeps commitments, inspires the trust of others, works with integrity, models ethical behavior, upholds the values of the organization, arrives on time for work, does not go beyond prescribed breaks, respects the property of others, etc.

Would the healthcare record retention criteria change if the healthcare facility closed?


MPI Master Patient Index

A listing or database of all the patients treated by a health care facility, indexed according to an indentification process.

Clinical data

Lab results, imaging reports, etc

Health Care Data uses

evidence of patient care, indicate quality of patient care, support educational efforts,support research, support compliance efforts, support reimbursement, support planning efforts of governmental entities, support employment decisions, support public health efforts, verify disabilities.

Three main groups that share responsibility for the Health Care organization's compliance with the requirements for collecting and maintaining clinical data are

The healthcare provider, The HIM professional, Health Care organization's health record committee.

The Healthcare providers

provide patient care and document the care rendered in a manner which is accurate, complete, and clinically pertinent.

HIM professionals

administer policies uniformly and develop procedures to facilitate completion of incomplete records and compliance with external and internal standards.

Health care organizations Health record committee

sets the organization's standards for quality of the healthcare record, including the terminology and abbreviations which will be used.

Advantages of an electronic health record over a paper based Health record

-paper record is static where a database is not,
-paper record can only be in one place at one time whereas a database may be accessed from multiple locations.
-paper record has a fixed order for organizing the data whereas a database can retrieve data in different sorting orders and be selective based on user criteria.
-paper record makes the viewer browse multiple pages searching for data whereas a database allows almost instant access to the latest available and valid data.

Each DRG represents

the average resources needed to treat patients found in the DRG.

Quality Health Care means

doing the right thing at the right time, in the right way, for the right person, and getting the best possible results.

Achieving quality in health care management is the result of the

dedication of a variety of professionals in all levels of employment and in all aspects of health care.

To make the PPS Prospective payment system work

Medicare adopted the Diagnosis Related Group or DRG.

Initiation of the DRG resulted in

significant cost savings to Medicare.

Which coding schemes are most commonly used today?

ICD-9-CM and CPT


A model that is a classification system which groups patients who are medically related by diagnosis, treatment, length of stay, age, and sex

Tools to address an issue or problem

brainstorming and


the process of comparing outcomes with those of an acknowledged superior performer

OASIS reports are used

in a home health facility

ORYX initiative

initiative by JCAHO where performance data is used to examine a healthcare organization's internal performance over time and to compare organization's performance with that of others.

Information is best defined as

knowledge resulting from the processing of data

Concurrency control

two patients are scheduled for the same time slot when using the computer scheduling system


is an effective tool for analysis of population characteristics by inference from sampling.

Vital statistics

number of deaths at a facility, number of births at a facility

What is the percentage of increase in workload if a provider was seeing 20 but now sees 30 patients a day?


Pie chart

A graph that presents the frequency of data through the use of a circle drawn and divided into sections that correspond to the frequency in each catagory.

What factors greatly influenced the growth of managed care?

Inflation and legislative changes


A payment methodology that is set by a formula for a set amount regardless of quantity or nature of services rendered.

HIPAA Transactions Rule

HIPAA rule that requires covered entities who transmit certain patient data electronically to use specific electronic transactions and code sets.

Clinical vocabulary

a vocabulary that specializes in words or phrases of a clinical or medical nature

Medical language

The words, their pronunciation, and the methods of combining them that has been established by long usage and understood by the medical profession

clinical terminology

a recognized system of preferred clinical or medical terminology


a chosen set of words, usually arranged in alphabetical order, understood and accepted by a community


also referred to as terminology

coding process

when data is manipulated

interpreting process

when data is used

documentation process

when data is entered into the record

performance improvement

improvement of performance as it relates to patient care

abstracting process

when data is retrieved from the record

indexing and registry process

when data is processed

quality assurance

actions taken to establish, protect, promote, and improve the quality of health care.

steps a group would follow using the FOCUS PDCA in chronological order

1-find a process to improve
2-organize a team that knows the process
3-clarify the current knowledge of the process
4-understand the causes of special variation
5-select the process improvement

pie chart

graph used to show relations to the whole

affinity diagram

diagram that organizes information into a visual pattern to show the relationship between factors in a problem

bar graph

demonstrates the frequency of data through the use of horizontal and vertical axes


contains both x and y axes and can display data proportionally

Pert (Program evaluation and review technique)

tool used to track activities according to a time sequence, showing the interdependence of activities

control chart

graph with statistically generated upper and lower control limits used to measure key processes over time

nominal group technique

organizes ideas wherein a list of ideas are labelled alphabetically and then prioritized.

cause-and-effect diagram

identifies major categories of factors which influence an effect and the sub factors within each category; also called the fish-bone or Ishikawa diagram.

pareto chart

bar graph used to identify and separate major and minor problems

gantt charts

graphic representations which show the time relationships in a project

Medicare Part B

covers physician fees, outpatient hospital services, and home health care services for those over 65 years of age

Medicare Part C

expanded coverage for those over 65 years of age


program designed to provide financing for the poor and impoverished

Medicare Part D

covers prescription care for those over 65 years of age

worker's compensation

covers employees who suffer work-related injuries


covers active duty members of the armed services.

Areas of knowledge/skills of a good coder

-knowledge and understanding of biomedical sciences, information technology, health care data content and structure, health care delivery systems, and reimbursement methodologies.
-possess skill with the coding schemes employed most commonly in the United States today (ICD-9-CM and CPT)

HL7 focus

HL7 develops specifications that allow different health care software applications within an organization to communicate with one another.

X12 focus

The X12 develops specifications for communication between software applications. It differs in that the focus is on developing a national standard for exchanging business information so as to facilitate business-to-business operations.


is a data set mandated by the federal government for those facilities treating Medicare and Medicaid patients. Since virtually all short-term general hospitals treat Medicare and Medicaid patients, the UHDDA has become the standard for reporting.

Six graphing rules that apply to most situations

1-the graph should be self-explanatory
2-the scale used should be easily readable
3-if more than one curve or line is displayed on a single graph for comparison purposes, the curves or lines should be differentiated from each other
4-the starting point of the graph should be clearly marked
5-the independent and dependent variables should be plotted on the generally accepted axis (the independent variable on the X-axis and the dependent variable on the Y-axis)
6-an accuracy check should be conducted for each graph created

What employees are exempt from the minimum wage provisions of FLSA (Federal Labor Standards Act)

If the employee is paid a salary rather than a wage

Steps of the disciplinary process

1-oral warning
2-written warning
3-written reprimand
4-suspension without pay
6-termination of employment

Directing others includes

continuous process of decision making, instructing others, and giving orders.

Involuntary separation

involves the employers decision to end a person's employment and are the result of the employer's choice.

Change management

is central to all business due to the magnitude and frequency of changes that occur in today's environment. All companies want to stay viable must anticipate and respond to these changes.

What three factors must be present for the study to be a true experimental design?



using the application of technology to facilitate the learning process

A network consists of

both printers and computers

information systems cycle

refers to the succession of stages of an information system

delegating authority

to transfer some of a manager's decision making authority to subordinates

key to supervision

recognizing that work is done through other people

What is the function of HTML

It describes what a Web page should look like.

HIPAA does not require a researcher using de-identified data go through the

IRB review process


refers to both physical and mental impairment

qualitative research

an investigator has a hypothesis and conducts research then interprets the data to build a theory

Motivators in the workplace

opportunities for personal or professional growth, achievement, autonomy, advancement, responsibility, recognition

role of OSHA

The federal act sets mandatory standards for safety and health for all employees. It requires employers to operate a place of employment that is free from recognized hazards that are likely to cause serious injury or a fatality

Federal law offers protections against age discrimination to workers who are over what age?

40 years old

performance standards

describes the results that must be achieved while doing a job

The larger the number of participants

the better the validity of the findings


springs from needs not yet fulfilled

Leaders with positional power would be

noted on the organizational chart, but leaders with personal power would not always be

Epidemiologists have started to focus their attention as it is the fastest growing problem in the United States

chronic and degenerative diseases

ISP Internet Service Providers

only a few connect directly to the Internet backbone


The reliability of data means the accuracy of a measurement and whether the measurement represents reality.


refers to the repeatability of a measurement. The measurement is evaluated to see if the conditions of measurement were standardized.

Health Care Informatics

concentrates on how to use technology to facilitate acquiring, processing, interpreting, and communicating health care data


Institutional Review Board


a group formally designated by an institution to safeguard the rights and welfare of human subjects

.com,.edu,.gov are examples of

domain types

data aggregation study

involves the collection of data from large numbers of medical records with out focusing on direct patient contact

what is the best way to avoid loss of data

to have a rigorous back up regime

humanistic management

as a result of the Hawthorne studies, managers became more aware of the need to focus on social relationships in the workplace

preventing damage

a company installs firewalls and virus scanning to address this security measure

The ADA (Americans with Disabilities Act)

applies to employees, job applicants, customers, and visitors

variation or deviation

a manager analyzes and compares data against the standard set for an activity, when standards are not met this data is called...

blind study

the participant is not informed but the clinician knows which participants have been assigned to receive the experimental intervention

double-blind study

neither the patient nor the clinicians involved are aware of which participants have been assigned to receive the experimental intervention.


those activities that outline what needs to be done and how to accomplish that effort

Belmont report

in response to medical research abuses, the National Commission published what many consider the landmark document in the area of human subject research ethics

healthcare information systems

cover a broad range of applications, serving both clinical and administrative functions

vision statement

an idealized goal that proposes a new future for an organization


refers to the benefits which accrue to the individual receiving care


refers to the resources consumed by the treatment

risk assessment

a method used to measure an organization's level of preparedness to prevent and recover from a disaster

An independent contractor

is an individual who agrees to perform certain work according to his own means, manner, and methods of performance

part-time employee

works less than 30 hours per week

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