Upgrade to remove ads
HIM Ch. 6
Terms in this set (39)
Primary Data Source
-The Health Record: contains information about a patient that has been documented by the professionals who provided care or service to that patient.
Secondary Data Source
Data taken from the primary health record and entered into registries and databases are considered a secondary data source.
-the health record contains information such as the patient's name and maintained in an identifiable form.
-include data on groups of people or patients without identifying any particular patient individually.
-secondary data are considered aggregate data
-is simply a report from a database that enables health records to be located by diagnosis, procedure, or physician .
Master Patient Index (MPI)
-is sometimes called the master person index contains patient-identifiable data such as name, address, date of birth, dates of hospitalizations or encounters, name of attending physician, and health record number.
-is a listing in diagnosis code number order for patients discharged from the facility during a particular time period in an acute setting.
-is similar to the disease index except that it is arranged in numerical order by the pt's procedure code(s), usually using ICD or CPT codes.
-is a listing of cases in order by physician name or physician identification number.
-are different from indexes in that they contain more extensive data.
-the process where each registry must define the cases that are to be included
-includes the methods used to identify the pt's who have been seen and treated in the facility for the particular disease or condition of interest to the registry.
-located within a facility such as a hospital or clinic
-gathering information from more than one facility within a geographic area such as a state or region.
-assigned when a case is entered into the registry this number is used to identify the pt.
-of all cases can be kept manually or provided as a report by the data-base software.
-is the process of determining the size and extent of spread of the tumor through-out the body.
-is a classification system that describes the extent of cancer within a pt.
Collaborative Stage Data
-standardized data set that uses computer algorithms to describe how far a cancer has spread.
is a wound or other injury caused by an external physical force such as an automobile accident, a shooting, stabbing or fall.
Abbreviated Injury Scale
-reflects the nature of the injury and the severity (threat to life) by body system.
Injury Severity Score
-is an overall severity measurement calculated from the AIS scores for the three most severe injuries of the pt.
Structed Query Language
-is the formal language used to retrieve information stored in relational databases.
-the most recent model to increase in use and a database management system
The Medicare Provider Analysis and Review (MEDPAR)
-file that is made up of acute-care hospital and skilled nursing facility claims data for all Medicare claims.
National Practitioner Data Bank
-was mandated under the Health Care Quality Improvement Act of 1986 to provide a database of medical malpractice payments; adverse licensure actions including revocations, suspensions, reprimands, censures, probations, and surrenders of licenses for quality of care purposes only and certain professional review actions taken by healthcare entities such as hospitals against physicians, dentists, and other healthcare providers.
Healthcare Integrity and Protection Data Bank
-developed for part of HIPAA mandated the collection of information on healthcare fraud and abuse because there was no central place to obtain this information.
-is an area of healthcare dealing with the health of populations in geographic areas such as states or countries.
National Center for Health Statistics (NCHS)
-has responsibility for a database of statistical health information to guide public health action and health policy making.
National Healthcare Survey
•One of the major national public health surveys
•To a large extent relies on data from patients' health records
-include data on births, deaths, fetal deaths, marriages, and divorces.
-is a research project in which new treatments and tests are investigated to determine whether they are safe and effective.
-which is a list of rules and procedures to be followed
Health Services Research
-is research concerning healthcare delivery systems, including organization and delivery systems, including organization and delivery and care effectiveness and efficiency.
Agency for Healthcare Research and Quality (AHRQ)
a federal agency established to improve the quality, safety, efficiency, and effectiveness of health care for Americans
Healthcare Cost and Utilization Project (HCUP)
•Uses data collected at the state level from either claims data or discharge-abstracted data, including the UHDDS items reported by individual hospitals and, in some cases, by freestanding ambulatory care centers
Medical Literature, Analysis, and Retrieval System Online (MEDLINE)
-is the best-known database from the National Library of Medicine
Unified Medical Language System (UMLS)
a program initiated by the National Library of Medicine to build an intelligent, automated system that can understand biomedical concepts, words, and expressions and their interrelationships; includes concepts and terms from many different source vocabularies
-is a set of descriptions of data items in a data model for reference for systems users.
Other sets by this creator
Health Record Law Final Exam Ch. 3, 5, 6, 7, 10, 1…
Health Record Law Final Exam Ch. 3, 5, 6, 7, 10, 1…
ScribeAmerica Course 5
Scribe America Course 4 Study Guide
Other Quizlet sets
Chapter 2 The Real Estate Services Act
BioChem Digestion EXAM 4
Anatomy Quiz for Organelles
Christ Everlasting Gospel Final Review Slides