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Study sets matching "health information management"

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Study sets matching "health information management"

61 terms
Health Information Management
Patient Demographics
Demographics include
Health care worker
Vital signs
Basic information about the patient.
Includes name, address, telephone number, gender, date of bir…
Person who participates directly or indirectly in providing h…
Includes height, weight, respiratory rate, pulse, blood press…
Patient Demographics
Basic information about the patient.
Demographics include
Includes name, address, telephone number, gender, date of bir…
44 terms
CPHI: Health Information Management
Demographics include
Medical record
Diagnostic services (Radiology)
Therapeutic services (Radiology)
Includes name, address, telephone number, gender, date of bir…
Includes patient demographics, signed patient confidentiality…
Used to diagnose medical conditions, includes x-ray, radioact…
Radiation and/or radioactive materials may be administered, i…
Demographics include
Includes name, address, telephone number, gender, date of bir…
Medical record
Includes patient demographics, signed patient confidentiality…
30 terms
Health Information Management
What is the healthcare documentation p…
Patient Demographics/Information
What is a healthcare worker?
What does SOAP stand for?
1. Patient visits physician... 2. Physician documents care provi…
Facts about the patient, as well as personal and medical info…
A healthcare worker is a person who participates directly or…
It is the process which is used to determine a diagnosis. Sub…
What is the healthcare documentation p…
1. Patient visits physician... 2. Physician documents care provi…
Patient Demographics/Information
Facts about the patient, as well as personal and medical info…
HEALTH INFORMATION MANAGEMENT
What type of patient care records incl…
In which setting may treatment records…
Which of the following wouldn't be doc…
Which of the following must be documen…
Hospice record
Correctional Facility care
Patients complete medical history.
Medicare condition
What type of patient care records incl…
Hospice record
In which setting may treatment records…
Correctional Facility care
15 terms
Health Information Management- Data and Information Quality and Management
As an HIM professional, I am involved…
_____ allows a user to insert, update,…
An organized collection of data is:
In the HL7 EHR functional model, the s…
Data quality
SQL
A database
Supportive
As an HIM professional, I am involved…
Data quality
_____ allows a user to insert, update,…
SQL
116 terms
Health Information Management
Continuity of Care Document
Clinical Data Repository
Interface
E-Discovery
Standard content being represented and mapped into the HL7's…
A central database that focuses on clinical information
The zone between different computer systems across which user…
Refers to Amendment to Federal Rules of Civil Procedure relat…
Continuity of Care Document
Standard content being represented and mapped into the HL7's…
Clinical Data Repository
A central database that focuses on clinical information
155 terms
health information management techology
accountable care organization
accreditation
acute care
admission to hospital
organization of healthcare providers accountable for quality…
voluntary process by which a healthcare facility demonstrates…
inpatient medical care of limited duration to diagnose treat…
patient is formally accepted into a hospital or inpatient hea…
accountable care organization
organization of healthcare providers accountable for quality…
accreditation
voluntary process by which a healthcare facility demonstrates…
202 terms
Health Information Management Final
1928
1928... American Health Information Manag…
to ensure the quality, confidentiality…
Attending Physician
Health information management (HIM) has been recognized as an…
The Association of Record Librarians of North American (ARLNA…
The underlying purpose of AHIMA is ____________.
Before 1918, the creation and management of hospital medical…
1928
Health information management (HIM) has been recognized as an…
1928... American Health Information Manag…
The Association of Record Librarians of North American (ARLNA…
25 terms
Health Information Management and Protection
What is the purpose of HIPAA?
What is the golden rule of documentati…
What is one primary purpose of HIPAA?
Covered Entity
The Health Insurance Portability and Accountability Act was e…
If it isn't written, it never happened.
To protect the confidentiality of patient records.
Anyone require to follow the Health Insurance Portability and…
What is the purpose of HIPAA?
The Health Insurance Portability and Accountability Act was e…
What is the golden rule of documentati…
If it isn't written, it never happened.
12 terms
Health Information Technology & Management
HIT (Health Information Technology)
PHIT (Personal Health Information Tech…
EHR (Electronic Health Record)
EMR (Electronic Medical Record)
The application of information processing involving both comp…
PHIT enables the documentation of an individual's complete li…
[A real time patient health record with access to evidence-ba…
A computer-based patient medical record. An EMR facilitates a…
HIT (Health Information Technology)
The application of information processing involving both comp…
PHIT (Personal Health Information Tech…
PHIT enables the documentation of an individual's complete li…
23 terms
Health information management
Quantitative analysis
Qualitative analysis
Healthcare documentation process
HIPAA
Review of the medical record to determine its completeness an…
Review of the medical record to ensure that standards are met…
Process by which the medical record containing the details of…
Security regulations and restrictions drveloped by the federa…
Quantitative analysis
Review of the medical record to determine its completeness an…
Qualitative analysis
Review of the medical record to ensure that standards are met…
30 terms
Health Information Management 4
patient record
demographic data
Medical Record Institute
information capture
serves as the business record for a patient encounter, contai…
patient identification information; SS number, DOB, address,…
MRI; categorizes health care documentation as information cap…
process of recording representations of human thought, percep…
patient record
serves as the business record for a patient encounter, contai…
demographic data
patient identification information; SS number, DOB, address,…
109 terms
Health Information Management Technology
The primary function of the American H…
Which of the following activities is n…
The traditional model of HIM practice…
The formal process for conferring a he…
Promote the accuracy, confidentiality, and accessibility of h…
Data administration
Department based
Certification
The primary function of the American H…
Promote the accuracy, confidentiality, and accessibility of h…
Which of the following activities is n…
Data administration
50 terms
Health information management technology
Data steward
Primary data source
Secondary data source
Indexes
To oversee the completeness and accuracy of the data abstract…
Contains information about a patient that has been documented…
Data contained in registries and similar data bases
Enable health records to be located by diagnosis, procedure,…
Data steward
To oversee the completeness and accuracy of the data abstract…
Primary data source
Contains information about a patient that has been documented…
17 terms
Health Information Management
electronic health record (EHR)
electronic medical record (EMR)
health information exhange (HIE)
health information management (HIM)
health information from all providers who have cared for a pa…
health information for a patient at one health care facility
the sharing of health care related for those working on the a…
the collection and analysis of health care data for the purpo…
electronic health record (EHR)
health information from all providers who have cared for a pa…
electronic medical record (EMR)
health information for a patient at one health care facility
8 terms
Health Information Management - Statements
registered medical transcriptionist
on the job
cancer registrar
claims examiner
the abbreviation RMT means
During the professional practice experience, students receive…
the collection of cancer data from a variety of sources and t…
a health insurance specialist reviews health-related claims t…
registered medical transcriptionist
the abbreviation RMT means
on the job
During the professional practice experience, students receive…
Health Information Management Vocabulary
abbreviation list
abstracting
abuse
accreditation
medical staff-approved abbreviations and symbols documented i…
data entry of codes and other pertinent information (patient…
pattern of practice inconsistent with sound business, fiscal…
voluntary process a health care facility undergoes to demonst…
abbreviation list
medical staff-approved abbreviations and symbols documented i…
abstracting
data entry of codes and other pertinent information (patient…
17 terms
Health Information and Management
AHIMA
Info in the database is only as reliab…
MSR
Validity
American Health Information Management Association
the person who entered it
Management of Strategic Resource
great care must be taken to that letters and numbers are not…
AHIMA
American Health Information Management Association
Info in the database is only as reliab…
the person who entered it
68 terms
Health Information Management Terms
accuracy
timeliness
comparibility
usability
the degree to which information in or derived from the databa…
the currency of the data at the time of release, determined b…
the extent to which databases are consistent over time and us…
the ease with which a database or registry's data may be unde…
accuracy
the degree to which information in or derived from the databa…
timeliness
the currency of the data at the time of release, determined b…
60 terms
Health Information Management Exam
ONC
HITECH
ARRA
Structured data
Office of the National Coordination for Health Information Te…
Health Information Technology for Economic and Clinical Health
American Recovery and Reinvestment Act
computer readable, having distinct values containing finite n…
ONC
Office of the National Coordination for Health Information Te…
HITECH
Health Information Technology for Economic and Clinical Health
110 terms
Health Information Management
CHIMA
What is Health Information Management
What does CHIMA oversee?
What is paramount in the health record…
Canadian Health Information Management
CHIMA defines health information management as the discipline…
Correct handling of Health Information throughout it's life c…
privacy security and confidentiality
CHIMA
Canadian Health Information Management
What is Health Information Management
CHIMA defines health information management as the discipline…
84 terms
Health Information Systems Management
The purpose of information systems is…
computer-based information system (CBI…
Transaction processing systems (TPS) c…
Management information systems (MIS) r…
The purpose of information systems is to get useful informati…
computer-based information system (CBIS) are people, processe…
Common business transactions include employee payroll, custom…
MIS provide performance reports based on the results from tra…
The purpose of information systems is…
The purpose of information systems is to get useful informati…
computer-based information system (CBI…
computer-based information system (CBIS) are people, processe…
13 terms
Health Information Management Technology
Certification
Credential
Registration
Documentation
The process by which a duly authorized body evaluates and rec…
A formal agreement granting an individual permission to pract…
The act of enrolling
The recording of pertinent healthcare as a business record an…
Certification
The process by which a duly authorized body evaluates and rec…
Credential
A formal agreement granting an individual permission to pract…
9 terms
Health Information Management
Ambulatory Patient Classification (APC)
Current Procedural Terminology, 4th Ed…
Diagnosis-Related Groups (DRGs)
Electronic Medical Record (EMR)
*Classification system of patients based on the International…
Comprehensive listing of medical terms and codes for the unif…
System that categorizes into payment groups patients who ar…
Electronic health record system generally considered as the p…
Ambulatory Patient Classification (APC)
*Classification system of patients based on the International…
Current Procedural Terminology, 4th Ed…
Comprehensive listing of medical terms and codes for the unif…
17 terms
health information management
progress notes are usually filed in wh…
the medical record belongs to the
the document stating the patient agree…
a method which speeds the filing process
chronological
physician
consent
color coding
progress notes are usually filed in wh…
chronological
the medical record belongs to the
physician
26 terms
Health Information Management
adverse event
authenticated
benchmarks
circumvent
an injury caused by medical management rather than the underl…
proved; with regard to medical records, it applies to a signa…
items or factors that serve as standards against which other…
to manage to get around, especially by ingenuity or strategy
adverse event
an injury caused by medical management rather than the underl…
authenticated
proved; with regard to medical records, it applies to a signa…
10 terms
Health Information Management
Acute Iymphocytic leukemia
Array
Cesarean delivery
Chemotherapy
a type of cancer that effects the white blood cells.
variety.
a surgical procedure to deliver a baby when the mother is not…
the use of powerful medications to kill diseased cancer cells.
Acute Iymphocytic leukemia
a type of cancer that effects the white blood cells.
Array
variety.
39 terms
health information management
health information
privacy
health info privacy
confidentiality
all info gathered about a patient
persons claim to limit access by others to some aspect of life
persons claim to control the way in which health info is coll…
trust between individuals in a patient-physician relationship
health information
all info gathered about a patient
privacy
persons claim to limit access by others to some aspect of life
10 terms
health information management
Adjudication
Brand name drug
Generic drug
Diagnostic test
the process used to determine finance payment
a drug that has been patented
the pharmaceutical equivalent to one or more brand name drugs
medically necessary test and/or non surgically procedure orde…
Adjudication
the process used to determine finance payment
Brand name drug
a drug that has been patented
44 terms
Health Information Management
UHDDS
Health Record
Consultation
Lab Report
Uniform Hospital Discharge Data Set
Paper or computer-based tool for collecting & storing info ab…
Report by any physician other than the primary care/attending…
Results of examination of bodily substances
UHDDS
Uniform Hospital Discharge Data Set
Health Record
Paper or computer-based tool for collecting & storing info ab…
11 terms
Health Information Management - Statements
freestanding, hospital based
primary care provider's office
appropriate
short stay or one day surgery
Ambulatory care allows patients to receive care in one day ca…
A referred outpatient receives diagnostic or therapeutic serv…
Medicare will reimburse sub acute care facilities if the care…
Ambulatory surgery, also called ________ or ________ is elect…
freestanding, hospital based
Ambulatory care allows patients to receive care in one day ca…
primary care provider's office
A referred outpatient receives diagnostic or therapeutic serv…
10 terms
Health Information Management
True
Generic Drug
Out-patient
True
T/F: The reason for using medical terminology is that it's im…
A drug that is the pharmaceutical equivalent to one or more b…
Patient who receives hospital care without being admitted as…
T/F: Detailed records help understand medical professionals d…
True
T/F: The reason for using medical terminology is that it's im…
Generic Drug
A drug that is the pharmaceutical equivalent to one or more b…
12 terms
Health Information Management - Statements
privacy officer
quality manager
RHIT, RHIA
a year
A health care professional who oversee the development, imple…
a nursing home administrator places the following advertiseme…
Which credentials does AHIMA sponsor?
AHIMA requires RHITs and RHIAs to submit proof of continuing…
privacy officer
A health care professional who oversee the development, imple…
quality manager
a nursing home administrator places the following advertiseme…
21 terms
Health Information Technology & Management
COB
MRI
SSL
SOAP
Coordination of Benefits
Magnetic Resonance Imaging
Secure Socket Layer
Subjective, Objective, Assessment and Plan
COB
Coordination of Benefits
MRI
Magnetic Resonance Imaging
15 terms
ABBRE. Health Information Management
ADL
DOB
Dx
FHx
activities of daily living
date of birth
diagnosis
family history
ADL
activities of daily living
DOB
date of birth
29 terms
Health Information Management Vocabulary
Acute lygmphocytic leukemia
Array
Cesarean delivery
Chemotherapy
a type of cancer that affects the white blood cells
variety
a surgical procedure to deliver a baby when the mother is not…
the use of powerful medications to kill diseased cancer cells
Acute lygmphocytic leukemia
a type of cancer that affects the white blood cells
Array
variety
29 terms
Health Information Management Words!
Acute Lymphocytic Leukemia
Array
Cesarean Delivery
Chemotherapy
A Type Of Cancer That Affects The White Blood Cells
Variety
A Surgical Procedure To Deliver A Baby When The Mother Is Not…
The Use Of Powerful Medications To Kill Diseased Cancer Cells
Acute Lymphocytic Leukemia
A Type Of Cancer That Affects The White Blood Cells
Array
Variety
47 terms
Health information management
Subjective
Objective
Assessment
Plan
Patients statement about hiw he feels (soap note)
Observations about the parient such as physical findings or l…
Judgement , opinion or evaluation made by the health care pro…
Diagnostic , therapeutic and educational plans to resolve the…
Subjective
Patients statement about hiw he feels (soap note)
Objective
Observations about the parient such as physical findings or l…
109 terms
Health Information Management Technology
The primary function of the American H…
Which of the following activities is n…
The traditional model of HIM practice…
The formal process for conferring a he…
Promote the accuracy, confidentiality, and accessibility of h…
Data administration
Department based
Certification
The primary function of the American H…
Promote the accuracy, confidentiality, and accessibility of h…
Which of the following activities is n…
Data administration
32 terms
Health Information Management
System
Information System
Health Information System
Health Management Information System…
A collection of components working together to achieve a comm…
A system which provides information support to the decision-m…
A system which integrates data:... -collection... -processing... -repo…
An information system specially designed to assist in the man…
System
A collection of components working together to achieve a comm…
Information System
A system which provides information support to the decision-m…
20 terms
Health information management #21
Progress notes are usually filed in wh…
The medical record belong to the
The document stating patient agrees to…
A method which speeds the filing process
Chronological
Physician
Consent
Color coding
Progress notes are usually filed in wh…
Chronological
The medical record belong to the
Physician
49 terms
Chapter 16 Health Information Management
Adverse Event
Authenticated
Benchmarks
Circumvent
An injury caused by medical management rather than the underl…
Proved; with regard to medical records, it applies to a signa…
Items or factors that serve as standards against which other…
To manage to get around, especially by ingenuity or strategy.
Adverse Event
An injury caused by medical management rather than the underl…
Authenticated
Proved; with regard to medical records, it applies to a signa…
9 terms
Health information management final
HIM has been recognized as an allied h…
The hospital standardization movement…
Critique this statement: The HIM profe…
The traditional model of HIM practice…
1928
American college of surgeons
The HIM professional's role in more enterprise focused
Department focused
HIM has been recognized as an allied h…
1928
The hospital standardization movement…
American college of surgeons
15 terms
Health Information Management
What consists of an outpatient medical…
What consists of the inpatient medical…
What does MPI stand for?
What is the purpose of MPI?
face sheet, progress notes, consultations, history and physic…
discharge summary, consultations, history and physical, opera…
Master Patient Index
a guide that is able to locate or retrieve data about the pat…
What consists of an outpatient medical…
face sheet, progress notes, consultations, history and physic…
What consists of the inpatient medical…
discharge summary, consultations, history and physical, opera…
10 terms
Health Information Management
Outpatient
True or False? Bailey was illegally ac…
Premium
Billy's friend wanted his medical file…
Treatment for a patient that does not require an overnight st…
False; it is very minor.
The amount a person pays to have insurance coverage.
The doctor and the nurses directly responsible for his care.
Outpatient
Treatment for a patient that does not require an overnight st…
True or False? Bailey was illegally ac…
False; it is very minor.
16 terms
Health Records and Health Information Management
Ambulatory Patient Classifications (AP…
Diagnosis-Related Groups (DRGs)
Electronic Health Record (EHR)/Electro…
Healthcare Facilities Accreditation Pr…
Classification system of patients based on the International…
System that categorizes into payment groups patients who are…
Electronic health record system generally considered as the p…
Accreditation program of the American Osteopathic Association…
Ambulatory Patient Classifications (AP…
Classification system of patients based on the International…
Diagnosis-Related Groups (DRGs)
System that categorizes into payment groups patients who are…
33 terms
Chapter 1 Health Information Management Profession
Accreditation
Active membership
American Academy of Professional Coders
American Association of Medical Record…
1. A voluntary process of institutional or organizational rev…
Individuals interested in the AHIMA purpose and willing to ab…
The American Academy of Professional Coders provides certifie…
The name adopted by the Association of Record Librarians of N…
Accreditation
1. A voluntary process of institutional or organizational rev…
Active membership
Individuals interested in the AHIMA purpose and willing to ab…
22 terms
Health Records and Health Information Management
Patient Health records
HIPAA
HIPAA violation
use of patient health records
An important Legal document admissible as evidence
Health Insurance Portability and Accountability Act of 1996... e…
Number one reason health care professionals may lose a job.
-means of communication between the attending physicians and…
Patient Health records
An important Legal document admissible as evidence
HIPAA
Health Insurance Portability and Accountability Act of 1996... e…
69 terms
Health Information Management Chapter 15
CIS
CPR
CPOE
(POC)
Clinical information systems
computer-based patient record
Computerized provider order entry
Point-of-care charting (POC)
CIS
Clinical information systems
CPR
computer-based patient record
78 terms
Health Information Management Chapter 7
Numbering systems
Serial Numbering System
Unit Numbering System
Social Security Numbering
Identify and file patient records according to preassigned nu…
A new number is assigned by the provider and a new patient re…
The patient is assigned a patient number the first time they…
A patients social security number is assigned as their patien…
Numbering systems
Identify and file patient records according to preassigned nu…
Serial Numbering System
A new number is assigned by the provider and a new patient re…
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