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chapter 5 HIM

Terms in this set (63)

father died of stomach cancer, mom died of a heart attack, two sisters were killed in an airplane accident in 1945.
social history
this is completed and documented no more than 30 days before or 24 hours after admission or registration, but prior to surgery or a procedure requiring anesthesia services. this must be placed in the patients medical record within 24 hours, but prior to surgery.
medical history and physical examination
is required by the Department of Health and Human Services. This core set of data elements is collected by acute-care, short-term hospitals to report inpatient data elements in a standardized manner.
Uniform Hospital Discharge Data Set (UHDDS)
this must be completed within 30 days following discharge. If the patients stay is not complicated and lasts less than 48 hours or involves and uncomplicated delivery of a normal newborn, a discharge note in place of a full summary is often acceptable. this summarized the outcome if hospitalization, disposition of case, and provisions for follow up care.
discharge summary
conducting or completing a security risk analysis including the security of health information. including security updates as needed with the identification of security deficiencies.
protect patient health information
these forms allow for electronic data entry and extraction online.
automated forms processing technology
this is occurring more frequently as healthcare organizations become more technology oriented. this is stealing medical coverage data, social security numbers, and other personal info to scam people and to sell to other hackers.
medical identify theft
a cesarean delivery is considered an operative procedure, thus requiring this type of consent
informed consent
health records of the mother, and her newborn infant, must be maintained-----
separately
surgical in nature, or Carrie's a procedural risk, or Carrie's and anesthetic risk or requires specialized training.
significant procedure.
a report that provides details of the examination of a body after death to determine the cause of death
autopsy report.
all of these must be dated, timed, and authenticated promptly by the practitioner who is responsible for the care of the patient only If such a practitioner is acting in accordance with state law, including scope of practice laws, hospital policies and medical staff bylaws, rules, and regulations
all orders
a condition the patient is known to have prior to being admitted to the hospital
comorbidity
develops after the patient has been formally admitted to the hospital
complication
tests on urine, blood or sputum would be found on this type of documentation
a lab report
MPI
Master Patient Index
the condition established, after study, to be chiefly responsible for occasioning the admission of the patient to the hospital
principal diagnosis
also known as a metadata repository. this is a repository of data elements used in an information technology system used in healthcare. examples of data elements include patient name, height, weight. diagnosis, age, and date of birth
data dictionary
this functionality provides clinicians with the ability to enter orders for medications, supplies, and radiology
computerized physician order entry (CPOE)
HIPAA
Health Insurance Portability and Accountability Act
this technology organizes and shares documents. it also functions to provide document version control, access and retrieval, and search functionality.
document management technology
this technology allows signature and document authentication. the document and signature cannot be changed or used by another user.
digital signature management technology
this is an example of what type of documentation. "100 mg of penicillin per mouth administrated at 8 am"
medication administration record or MAR
this technology provides provides authentication, secure documents, and system reliability
electronic records management technology
the joint commission directs that all health organizations that prescribe medications must precisely and completely reconcile medications
medication reconciliation
what is a trending potential barrier to EHR implementation that causes computer systems to cease operations completely?
cybersecurity attack
which of the following would be considered a speciality based EHR?
Neurology practice EHR
t or f? a cybersecurity attack does not have the potential to cease computer operations throughout an organization.
false. they can impact the whole organization
Speciality practices have the option to select a speciality custom or predesigned templates?
true
t or f? surveys have found that sending prescriptions electronically does not save time.
false.
which of these organizations mandates accreditation standards for discharge summaries?
the joint commission
which of these phases includes the distribution of the proposal?
disposition phase
when is financial data collected?
registration
the notice of privacy practices tells a patient how health information is used by an organization. true or false?
true
speciality physicians received special training and education in a field that focuses on a particular part of the body or disease. true or false?
true
mobile devices are not allowed in healthcare. true or false.
false. mobile devices are common and are used to access information.
who is primarily responsible for completing the discharge summary?
attending physician
which document captures a patients past medical experiences?
medical history
which of the following details are included in the autopsy report?
incidental findings
a detailed log of the hybrid record should include
place of storage
EHRs can be authenticated by
digital signature
the process of abstracting involves the following
extracting
preliminary clinical data is collected following admission. true or false.
false
information in the EHR cannot be a part of the legal health record. true or false?
false
mobile devices can be used to remote patient monitoring. true or false?
true
the conditions of participation include information about physician authentication. true or false?
true
discharge summaries must include a patients condition at discharge. true or false?
true
which of the following represents paper and electronic documentation?
hybrid records
true or false? EHR entries are authenticated using electronic signatures, digital signatures, biometric verification, and public key certifications.
true
biometric verifications are based on unique identification characteristics of an individual like fingerprints, biological traits, hand geometry, retina and iris patterns. true or false?
true
which services does CARF offer accreditation programs for?
rehabilitation
what document is a reference document for patients after they have been released from the hospital?
discharge
which of these processes supports the auxiliary utilization of patient information for registries, public reporting, research, and various purposes?
abstracting
which of these has the ability to pull data from different sources, they are designed to receive very large amounts of data and perform analytical processes on the data?
data warehouse
the functionality of an EHR can reduce workload and improve efficiency.
true
which of these are known as a common type of fraud in healthcare?
providing unneccessary services to patients to increase payment
identity theives are stealing which of the following health information?
medical coverage data
policies and procedures must be developed to address integrity issues
true
which of the following documents is a clinical document?
physical examination
this organization is known for developing messaging or data exchange standards?
HL7
speciality practices collect data and information that may not be collected in acute-care settings.
true
speciality providers are identified as -----under meaningful use
eligible professionals
what are the 5 suggest standards published by ONC to obtain interoperability
vocabulary and terminology standards defined as a structured list of
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