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Terms in this set (76)
Outpatient services include:
diagnostic, therapeutic, and rehabilitation
Uniform Ambulatory Care Data Set
Uniform Ambulatory Care Data Set is the:
minimum core data set collected on medicare and medicaid outpatients
Medical or surgical care that does not include an overnight hospital stay.
Professional contact between a patient and a provider during which services are delivered.
Outpatient visit to a hospital department to receive ordered service, test, or procedure.
Ancillary service visit
First listed diagnosis in an outpatient setting:
Content and organizations depends on size, ownership, and accreditation. Minimally should contain patient registration information, problem list, medication list, progress notes, result or ancillary services.
Physician office record
Form used in physician offices that contains commonly used services and their codes.
Patient is assigned a number for each encounter at a facility.
Serial Numbering system
Patient is assigned an identification number at the first encounter and retains the same number for all subsequent encounters.
Patient is assigned a new number for each encounter and records from previous encounter are moved to the new number.
Patient's lastname, firstname, and middle initial are used to file their health record.
Alphabetic Filing System
3 types of numeric filing:
straight, terminal, middle digit
Records are filed in strict chronological order; also called consecutive numeric filing
Straight Numeric Filing
Patient number is divided into 3 parts and is read from left to right; also called reverse numeric filing
Terminal digit filing
A variation of terminal digit filing, assigns middle digits as primary and remainder digits are read from left to right.
Middle digit filing
All records are organized in a single location.
centralized filing system
Records are organized throughout the facility in the patient care areas that create and use them.
decentralized filing system
vertical and lateral filing cabinets, open shelves, or compressible filing units can all be used.
store paper based records; color coded, durable, variety of sizes & weights, customizable
identifies where the record is located and when it was removed.
allows providers to request records via a computer
chart tracking system
to ensure records are returned in a timely fashion
audit of file area
all records should be stored in an area or a room that can be locked to prevent theft, tampering, or other unauthorized use.
security of health information
an organized list of specific data that serves to guide, indicate, or otherwise facilitate reference to the data
links a patient's medical record number to patient indentifiable data, the key to locating the paper based health record
Master Patient Index (MPI)
computerized database of patient identification information about patient's who have received services from the facility.
requires typing or manual posting of patient identification information usually onto preprinted index cards.
Can occur when facilities merge?
listing in diagnosis code number order for patient's discharged from the facility
list of operations and surgical procedures performed in a healthcare facility
procedure or operation index
list of patients and their physicians that is usually arranged by the physicians code number assigned by the facility
contain information about a disease or event, maintained by healthcare facilities, govt agencies, etc.
reporting is submitted by health care facilities and providers to report data to responsible agencies, facilities, and organizations.
registers and registries
collection of information and used to verify information
example of registers:
organized system for collecting and maintaining information about a defined population and used to collect and sort data
example of a registries
or birth defects
performed by HIM dept to collect patient information to determine prospective payment system, generate indexes, and report data to quality improvement organizations and state and federal agencies.
a standard method for collecting and reporting individual elements must be established.
ex: UADDS or UHDDS
summarize a set of data using charts, graphs, and tables
accessibility, accuracy, comprehensiveness, consistency, definition, granularity, precision, relevancy, timeliness, and currency are what?
characteristics of data quality
admission data, length of stay (LOS), total length of stay, average length of stay, and discharge data are what?
hospital based statistics
system of tools for dealing with disputes and problems
sometimes called private law, does not include criminal law, involves lawsuits between private parties and individuals/Corporations/Govt
concerns the relationship between govt and private-citizens/private-organizations/other govt agencies.
the legal process lawyers use to obtain information about all aspects of a case
form of discovery that includes a list of written questions that must be answered by the party served to either defendant or plaintiff.
a form of discovery used to learn answers to certain questions, obtain a sworn statement from defendant, observe a witness' behavior and ability to testify, and discover weaknesses and strengths in each party's case.
administrative, case, statutory
sources of law
legislature assigns power to agencies to create rules and regulations, and make decisions about failures to comply with rules.
also called common law, is based on judicial decisions and precendent
a legal business record that must be maintained
a health record
establish national privacy protection standards for all forms of health information
establish national standards for the security of electronic health information
protected health information
treatment, payment, operations
system of terms that follow pre-established naming conventions
international classification of diseases, 10th revision, clinical modification
international classification of diseases, 10th revision, procedure coding system
current procedural terminology
healthcare common procedural coding system level
hospital insurance that generally covers hospitals, skilled nursing facilities, hospice, and home health services.
medicare part A
medical insurance that is optional and supplemental (monthly premium)
medicare part B
medicare disadvantage, insurance plans offered by private companies and pays a fixed amount to the companies
medicare part C
prescription drug coverage
medicare part D
medicare administrative contractors
private health insurance, purchased by individuals, self-employed business owners, and groups of people
companies set aside the cost they would have paid in premiums for health coverage and use the funds to pay healthcare claims
employer self insurance plans
health maintenance organizations
preferred provider organizations
providers respectively receive payment for health care services provided to the patient
prospective payment system
diagnosis related group
updated to? MS-DRG
universal claim form
electronic data interchange
THIS SET IS OFTEN IN FOLDERS WITH...
Week 1 - Chapter 2
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