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quizlet for midterm health info req 1
Terms in this set (51)
The development of managed care services in the United States is an indirect result of the federal government's enactment of _____.
Medicare/Medicaid legislation of 1965
Medical staff bylaws are legally binding, and any changes must be approved by a vote of the _________.
________________ is used when the professional nursing care and related medical, therapeutic, psychosocial, and personal services is provided in a residential setting to individuals recovering from injuries or illnesses or the residual effects of injuries or illnesses after the acute phase of the condition has resolved?
Skilled Nursing Facility
continuum of care
______________ is the range of healthcare services provided to a patient, from routine ambulatory care to intensive acute care, with an emphasis on communication among caregivers.
As a result of the Flexner Report in the early part of the 20th century, ___________ were established for medical schools and medical education.
What is the main difference between primary, secondary, and tertiary care
degree of specialization
The ______ developed the first hospital standardization program. -
American College of Surgeons
__________________ is the term for health records maintained by patients and/or their families.
personal health record
_____ can be defined as a voluntary system of institutional review by an independent external agency.-
What is the name of the clinical document that is a concise summary of a hospital stay, including the reason for admission, significant findings from tests, procedures performed, therapies provided, response to treatment, condition at discharge, and instructions for medications, activity, diet, and follow-up care
P.L._____ is the federal legislation that enacted the Medicare and Medicaid programs.
-P.L. 89-97 of 1965
The concept of the continuum of care was initially developed in response to what trend in the healthcare environment?
increasing cost of healthcare
Which of the following is not among the principles in an HIE?
Collection, use, and disclosure limitation
Integration with a PHR
Openness and transparency
integration with a PHR
Which of the following statements most accurately describes the Medicare program?-
A federal program that finances healthcare services for the elderly
An _______________ moves health information among organizations while adhering to national standards.
Health Information Exchange
Which of the following statements most accurately describes funding for the Medicaid program?-
Funding is a joint federal and state initiative
In 2003 the __________, a public policy advisory board made up of representatives from numerous healthcare, trade, and professional organizations, recommended that standard-developing organizations be encouraged to adopt standards that promote interoperability of electronic health records and PHRs.
National Committee on Vital and Health Statistics
______ healthcare organizations pay out their excess revenues in the form of bonuses and dividends to owners, investors, and managers-
______ would be categorized as voluntary hospitals.
The primary goals of the __________ are to enable health information to follow the consumer, to make health information available for clinical decision making, and to support appropriate use of healthcare information beyond direct patient care.
National Health Information Network
The ______ is/are primarily responsible for determining the overall mission of an acute care hospital.
-Board of directors
Due to the widespread use of the Internet to distribute health-related information, Americans have become more aware of what?
The large quantity of personal information stored in their health records
______ refers to the organization of physicians according to clinical assignment.
-Medical staff classification
Hospital policy may allow orders to be accepted by any of the following except:!
What is data called that consists of factual details aggregated or summarized from a group of health records the provides no means to identify specific patients?
______ govern(s) the operation of a hospital medical staff.
-Medical staff bylaws
The ______ is/are responsible for implementing the policies and strategic direction of a healthcare organization on a day-to-day basis.
Codes are associated with reimbursement rates and therefore, there are inherent incentives to code so the healthcare facilities will receive the lowest reimbursement dollar amount possible.-
Family members can always have access to another family member's medical records.
HIM professionals are able to assist patients with the process of finding out what happened in case of medical identity theft and help guide the patient to fixing the errors in the record.-
The processes retention and destruction of health information are subject to specific regulations in many states as well as guidelines found in Federal regulations and _________ standards
Breach of healthcare ethics is the situation in which ethics are violated, whether it is intentional or accidental.-
The processes retention and destruction of health information are subject to specific regulations in many states as well as guidelines found in Federal regulations and _________ standards.
If a patient notices an unknown item in the Explanation of Benefits they receive from an insurance company and they do not recognize the service being paid for, the patient should
-Contact the insurer and the provider who billed for the services to correct the information
Health Insurance Portability and Accountability Act (HIPAA)'s Privacy Rule states that ___________ used for the purposes of treatment, payment, or healthcare operations does not require patient authorization to allow providers access, use, or disclosure. However, only the ___________ information needed to satisfy the specified purpose can be used or disclosed.
Protected health information; minimum necessary
Ethical obligation to the _______ include advocating change when patterns or system problems are not in the best interest of the patients, reporting violation of practice standards to the proper authorities.
The purpose and value of documenting in the patient's health record is effective communication to other caregivers for continuity of customer care.
The HIM department is involved in the __________ process by making the medical records of patients enrolled in a research study available to external monitors and auditors
-Institutional Review Board
___________________ is the ability to accept and understand the beliefs and values of other people and groups.
The ____________ owns the health records of patients treated in a healthcare facility
______________________ is the fraudulent use of an individual's identifying information in a healthcare setting.
-Medical Identity theft
What is the most important factor in determining the best storage method for health records?
Ensuring that the records are readily accessible and secure
Ensuring that the records are factual and informational
Ensuring that the records are both electronic and paper based
Ensuring that the records are personal and private
Ensuring that the records are readily accessible and secure
The ___________________ is tasked with reviewing ethics violations and determining the course of action required to remedy the violations. -
Ethical Principles and values have been important to the HIM profession since 1942.
What factor is medical necessity based on?
The beneficial effects of a service on the patient's physical needs and quality of life
________ is the outcome of analyzing data for a specific purpose
___________ is a process used to investigate a medical error that resulted in the death of
Before a physician will be permitted to provide patient services in a specific facility, he or she must first go through the___________ processes
Before a hospital is permitted to provide medical services in a particular state, the organization must first go through the ___________ processes.
The process of releasing health record documentation originally created by a different provider is called:
Burning, shredding, pulping, and pulverizing are all acceptable methods in which process?
Destruction of paper-based health records
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