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RHIT White Board Notes
Terms in this set (152)
Utilization Review (UR)
Process of determining whether the medical service provided to a
specific Medicare or Medicaid patient is necessary.
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.
When records for evidence is involved at the trial, the records custodian
is called a witness by one party or other to testify as the authenticity of a record as evidence.
The records custodian verifies that it contains information about the individual
Data that has been extracted from individual health records and combined
to form deidentified information about groups of patients that can be compared.
Mistakenly assigned another persons health record number
When a patient has more than one health record number at different locations within
The creation of a second record in an MPI on a single patient which occurs when a patient has been assigned multiple unique patient identifiers, results in a patient having multiple health records within a single healthcare organization.
To control/protect access of health information and records.
ROI Turnaround Time
Time between receipt of request and when the request is sent to the
30 days on site, 60 days off site.
Reviewing a record and ensuring that standards are being met. HIM
professionals can review legibility, timeliness of documentation, use of approved
abbreviations and other documentation standards.
A review of the health record to determine completeness and
accuracy. Is everything there? Any forms or signatures missing?
A review of the health record while the patient is still hospitalized or under treatment. From admission to discharge.
Review after patient has been discharged.
reviewing appropriateness and necessity of care provided to patients prior to administration of care.
Organizations are the legal authority from the authorities to carry on certain
activities that require permission. Before healthcare organizations can provide services, they
usually must obtain licensure by government entities such as the state or county in which they
Conditions of Participation and Conditions for Coverage
Administrative and operational guidelines under which facilities
are allowed to take part in the Medicare and Medicaid programs
The Joint Commission (TJC)
A private, not-for-profit organization that evaluates and accredits hospitals and other healthcare organizations on the basis of predefined performance standards; formerly known as the Joint Commission on Accreditation of Healthcare Organizations (JCAHO)
The right of a patient to control the disclosure of PHI
Legal and ethical concept that requires healthcare providers to protect
records and personal/private information. Responsibility to use, disclose or release
Meaningful Use, Stage 3
Stage three will focus on advanced decision support and population health. Using certified EHR technology to improvise quality safety,
efficiency, and reduce health disparities. Engage patients and family, improve care
coordination and population and public health.
Registration- Admission, Discharge, Transfer (R-ADT)
Uniform Hospital Discharge Data Set (UHDDS)
Used for reporting inpatient data in acute care, short-term care, and long-term care hospitals.
Minimum set of items based on standard definitions to provide consistent data for multiple users.
Required for reporting Medicare and Medicaid patients.
Many other health care payers also use most of the UHDDS for the uniform billing system.
-UB04 is a form used for this data set
Uniform Ambulatory Care Data Set (UACDS)
A data set developed by the National Committee on Vital and Health Statistics consisting of a minimum set of patient/client-specific data elements to be collected in ambulatory care settings
Healthcare Effectiveness Data and Information Set (HEDIS)
Designed to collect
administrative, claims, and health record review data.
Outcome 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 (CMS 2013)
Data Elements for Emergency Department Systems (DEEDS)
Minimum Data Set (MDS)
a comprehensive evaluation of the functional capabilities of each resident in a long-term care facility
Essential Medical Data Set (EMDS)
A recommended data set designed to create a health history for an individual patient treated in an emergency service
allows for connections between two systems. This connection allows for data initially captured for one purpose to be translated and used for another purpose. One system in a map is identified as the source while the other is the target.
Process of collecting data from sources within an organization for
decision making purposes.
-Single database that helps locate data that exists in multiple databases
data that describes other data
Case Mix Index (CMI)
The average relative weight of all cases treated a facility or by a given
physician. This is calculated by dividing the sum of the weights of DRGS for patients
discharged by the total number of patients discharged.
National Patient Safety Goals (NPSGs)
Goals issued by the Joint Commission to improve patient safety in healthcare organizations nationwide
False Claims Act (FCA)
Penalties to those who knowingly submit fraudulent claims to Government
List of charges for the healthcare services and supplies at an organization.
A graph that uses line segments to show changes that occur over time
Represents the frequency distribution of numerical data.
Like a bar graph but continuous
distributed in categories
Displays data points for specific time frame to provide information about
performance. In a run chart the measured points of a process are plotted on a graph at
regular time intervals so health team members identify whether there are substantial changes
in numbers over time.
the middle score in a distribution
most frequently occurring score
The zone between different computer systems across which users want to pass
information. Provides the hard wiring.
Principles describing how a department or organization will handle a specific
situation or evaluate a specific process. They are clear simple statements of how an HIM
department will conduct it's services.
Once policies are in place, procedures will define the processes by which the
policies are put into action. Procedures are written documents that describe the steps
involved in performing a specific function.
Yearly plan released by the OIG that outlines the focus for reviews, audits and investigations in various healthcare settings
National Practitioner Data Bank
Provide a database of medical malpractice payments,
adverse licensure actions and certain professional review actions taken by healthcare entities.
Compares organization standards against external organizations
Red Flag Rule
Used as triggers to alert organizations of potential identity theft.
Average length of Stay
25 days or less
Intentionally executes or attempts to execute a scheme to obtain money or any
healthcare benefit program
Checks the written standards of conduct, policies, procedures, and
audits that address the areas of potential fraud
Chief Privacy Officer (CPO)
Responsible for privacy practices within the organization, performs
privacy risk assessments, overseeing privacy training.
Office of Inspector General (OIG)
Office in the federal government working to combat
fraud, waste and abuse to improve the efficiency of HHS programs.
the process of establishing the medical need for medical services
Health Insurance Portability and Accountability Act (HIPAA)
United States legislation
enacted to control fraud and abuse in healthcare, reduce healthcare costs, provides data
privacy and security provisions for safeguarding medical information.
listing of all the data elements within a specific system that defines each
individual data element, standard input of the data element and specific data length.
Written statement detailing a person's desires regarding their medical treatment
in circumstances in which they're no longer able to express informed consent, especially an
Data derived from the primary patient record such as an index, registry or
database for things such as research and quality patient safety.
Records maintained by many states for the purpose of tracking the incidence (new cases) of cancer
administrative policies and procedures designed to protect electronic health information (computer resources) outlined by the HIPAA Security Rule
Master Patient Index (MPI)
A patient-identifying directory referencing all patients related to an organization and which also serves as a link to the patient record or information, facilitates patient identification, and assists in maintaining a longitudinal patient record from birth to death
Prohibits offering, paying, soliciting or receiving anything of value to induce or reward referrals or generate federal healthcare program business.
Noncustodial Parents rights to Medical Records
By law, a parent not granted custody of
a minor child has the same right as the custodial patent to the child's academic, medical,
hospital or other health records, unless otherwise order by the courts.
a report that traces who has accessed electronic information, when information was accessed, and whether any information was changed
Well-respected physician who can informally help physician
community adapt to and ultimately adopt health IT. Is the communicator between CDI and
Y-Diagnosis was present at time of inpatient admission
N- Diagnosis was not present at time of inpatient admission
U- Documentation insufficient to determine if the condition was present at the time of inpatient
W- Clinically undetermined. Provider unable to clinically determine whether the condition was
present at the time of inpatient admission.
Communication tool for CDI staff to communicate with providers to obtain clinical
clarification, provide a documentation alert, get documentation clarification or ask questions
Clinical Documentation Improvement (CDI)
The process an organization undertakes that will improve clinical specificity and documentation that will allow coders to assign more concise disease classification codes
Worksheet is a useful tool for documenting a test of
change. The PDSA cycle is shorthand for testing a change by... developing a plan to test the
change (Plan), carrying out the test (Do), observing and learning from the consequences
(Study), and determining what modifications should be made to the test (Act).
A challenge in extracting meaningful data from unstructured text.
Clinical notes often contain terms that have more than one meaning. Example: Cold- a
disease or body temperature/ Discharge- body fluid or leaving hospital
Front End- Patient Registration
Middle- The documentation of the encounter in the health record, charge capture &
Back End- Claims transmission, and accounts receivable
Complete Worked Hours
Total work output - defective work = complete worked hours
Completed Work / Hours worked to produce total work output
ARRA (American Recovery and Reinvestment Act)
Provides funds for adoption of technology and provides the right for every individual to receive electronic copy of EHR
HITECH Health Information Technology for Economic and Clinical Health- (created by
Allocates funds for implementation of a nationwide health information exchange and
implementation electronic health records.
Alphabetic Filing System
Filed alphabetically by patients last name
Straight numeric filing system
Filed based directly by the record number in numeric order.
Terminal-digit filing system
Filed by the last two digits (terminal digits) then the middle
two(secondary unit) then first two (tertiary units).
Centralized Unit Filing
The patients encounters are filed in a single location.
Alphanumeric Filing System
First two letters of patients last name followed by a unique
numeric identifier. Ex. SA1234
Images stored on a long roll of film, major problem is that patient encounters
can be stored on multiple rolls which can make retrieval difficult
Microfilm is cut and inserted into 4x6 inch jackets with sleeves
Copy of the jacket microfilm. Used to be sent out of the HIM Department instead
of using the original Jacket Microfilm.
Paper-based health record system to track the location of records removed.
Making sure that all the records have been received by the HIM
department after patient has been discharged.
Federal Agency within the US department of Health and Human Services.
-Oversight of Medicare program and state governments.
Conditions of Coverage
Ensures patient quality, safety and improvement of clinical
Accredited organizations must go through it's own CMS review in order to receive
deemed status (compliant with Conditions of Participation).
CMS & Joint Commission mandate the content of the bylaws (Med Staff)
Piece of legislation written and approved by state/federal legislature, signed to law.
Legal Health Record
Defined by each organizations
Documentation that supports revenue pursued by payers
Documentation used for legal testimony
Consent given by their words or in writing.
Inferred by patients action (like when patient sticks out arm for blood
Entity may not use or disclose protected health information without
consent, also a document required under Privacy Rule or HIPAA.
Emergency Medical Treatment and Active Labor Act- Determines if an emergency
Long Term Care
Skilled Nursing Care, Subacute Care facilities, nursing facilies (nursing
homes, assisted living). Care plan format is called Resident Assessment Instrument (RAI)-
based on Minimum Data Set (MDS)
Patient Assessment Instrument(PAI)
Completed shortly after admission and discharges
Rehab Facilities are accredited through CARF (Commission on Accreditation of
Average Length of Stay is 25 days or less.
Source Oriented Health Record
Record is organized by source. Example: All nursing notes
Serial Numbering System
System that makes unique numerical identifer number for every
encounter. Example: If a patient is admitted five times, he or she will have five different health
Unit Numbering System
(most common) Health record number is issued at first encounter
and used for all subsequent encounters.
Serial-Unit Numbering System
Issued a new medical record number with each encounter
and all documentation is moved from last number to new number.
Universal Chart Order
Reverse chronological order
Integrated Health Record
Placed in chronological order
Subjective, Objective, Assessment, Plan (SOAP)
Patient chart notes organized according to symptoms, signs, assessment, and plan
Problem Oriented Health Record
consists of problem list, H&P, lab findings, initial plan,
Information collected during day-to-day operations of an organization
that has value.
Free of errors
All data elements are collected
Ensuring all of the data is consistent and the same
Current and up to date
All data elements must be clearly defined
Data collected must be at appropriate level of detail
Data should be precise, in exact form. Example: height
Data is useful for the purpose it was collected
Documents should be entered promptly
Electronic Document Management System(EDMS)
Used to track manage and store
Assigning separate codes
Doing good or causing good to be done; kindly action
AHIMA Code of Ethics
Links the patient's information at the different facilities when they go to
multiple places .
Meaningful Use (MU)
The set of standards defined by the Centers for Medicare & Medicaid Services (CMS) Incentive Programs that governs the use of EHRs and allows eligible providers and hospitals to earn incentive payments by meeting specific criteria
Joint Commissions method for following patient
Health Information Exchange (HIE)
a network that enables the sharing of health-related information among provider organizations according to nationally recognized standards
Case Mix Index (CMI)
The distribution of a patient into categories reflecting difference in severity of
illness or resource consumption.
Don't code with other codes
Similar in appearance to a bar chart but the highest- ranking value is listed as
the first column and the next highest ranking is second and so forth.
Average of the squared deviations from the mean
Fair and Accurate Credit Transactions Act (FACTTA)
Protects consumers from identity
theft and responds to Red Flags.
Fixed rules that must be followed
a general rule, principle, or piece of advice.
unexpected occurrence involving death or serious injury. Adverse outcome.
Skilled Nursing Prospective Payment System
Resource Utilization Group (RUG)
Taken reasonable actions to comply
Intentionally failing to comply with HIPAA provisions.
Total number of delinquent records divided by/ number of discharges.
When healthcare providers or suppliers perform testing that is unnecessary to obtain
Medicare Provider Analysis and Review File (MEDPAR)
Data for all Medicare claims for
acute care hospital and skilled nursing facilities. Used to research topics related to types of
care and DRGs, but only for Medicare patients.
Process of extracting information from a database then quantifying and filtering
discrete, structured data. Data mining is a process used by companies to turn raw data into
A method used to identify the patients who have been seen or treated in the
facility for the particular disease or condition of interest to the registry.
Critical process of bringing data into a common format that allows for
collaborative research, large scale analytics, and sharing of sophisticated tools.
Board of Directors
Elected group who are responsible for successful operation of the
Ensure that each row in a table is unique. A primary key must not change in
value. Typically, a primary key is a number that is a one-up counter or a randomly generated
number in large databases. A number is used because a number processes faster than an
alphanumeric character. In large tables, this makes a difference. In the PATIENTS table, the
PATIENT_ID is the primary key. It is good programming practice to create a primary key that
is independent of the data in a table.
FTE (full time equivalent)
Ratio of total number of paid hours during a period by the number of working hours in that period. 1 FTE = 1 employee working full time in that period.
Total length of stay
The sum of the days of stay of any group of inpatients discharged during a specific period of time; also called discharge days
Average length of stay (ALOS)
total length of stay (discharge days)/ total discharges
number of people contracting a disease during a time period
Average Daily Inpatient Census
Total inpatient service days for a period (excluding newborns)/total number of days in the period
Which days are included in LOS?
All except the day of admission
What are nosocomial infections?
hospital acquired infections
What stats are considered "vital statistics"?
Birth, death, marriage, divorce, fetal death, and induced terminations of pregnancy
Who is responsible for maintaining the official vital stats of the US?
NVSS (National Vital Statistics System) of NCHS/CDC
Bed occupancy ratio
(Total inpatient service days in a period x100)/total bed count days in the period (bed count x number of days in the period)
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