HIM Technology : An Applied Approach
True or False: The metathesaurus, one of the UMLS knowledge sources, contains syntactic information for many terms.
False
True or False: With regard to data quality, validity refers to the consistency of the data.
False
True or False: Authorization is identifying a patient through the use of a user name
False
True or False: Data validation includes an undo button
False
True or false In a paper-based record, errors should be completely obliterated
False
Connection Setup Phase
Initiate a connection between computers on the network.
True
The health record is the principal repository for data and information about the healthcare services provided to individual patients.
3 types of information for authentication
something you know, something you have, or something you are. most common is the use of user names and passwords. Also Biometrics and access cards
True or False: A nosologist's primary responsibility is the assignment of diagnosis codes.
False
True or False: A patient health record contains aggregate data.
False
True or False: An encoder is computer software that assists in determining coding accuracy and reliability.
False
True or False: HIM professionals are not involved in developing policies and procedures for corporate compliance.
False
True or False: Medical staff members are external users of secondary data.
False
True or False: Now that registries and databases are almost universally electronic, data collection is done manually.
False
True or False: The 837I is also referred to as the 837P.
False
True or False: The UMLS knowledge sources are currently being used in natural language processing.
False
True or False: The UMLS project was initiated to bring together the various medical vocabularies.
False
What are the benefits of an electronic system?
ability to access data by more than one individual at a time, edit checks can be applied against specific fields in the database to better ensure data accuracy, can be easily cross-referenced (when a patient has used more than one name during hospital or clinic visits), permits the use of several search techniques for locating an existing patient's information.
administrative services only (ASO) contracts
an agreement between an employer and an insurance organiztion to adminster the employer's self-insured health plan
Hospital Standardization Program
an early twentieth-century survey mechnaism instituted by the American College of Surgeons and aimed at identifying quality of care problems and improving patient care;
electronic health record IEHR)
an electronic record of health related information on an individual that conforms to nationally recognized interoperability standards and that can be created, managed, and consulted by authorized clinicians and staff across more than one healthcare organization.
House of Delegates
an important component of the volunteer structure of the American Health Information Management Association that conducts the official busienss of the organization and functions as its legislative body
Commission of Certification for Health Informatics and Information Management (CCHIIM)
an independent body within AHIMA that serves the public and the profession by establishing and enforcing staqndards for the initial certificaiton and certificaiton maintenance of health informatics and infomraiton management professionals
privacy
an individuals right to control access to his or her personal information
third party payers
an insurance company that reimburses healthcare providers and/or patients for the delivery of medical services
Errors
another step to managing the quality data in EHR. Most generate error reports or utilize error queues when there are mismatches between the EHR and the other computer systems that feed information into the EHR. Must be a process in place to correct the errors.
Validation rules
are applied to data fields to determine the validity of data entered into the EHR. Features include:drop-down menus, built-in data values, and check boxes. They do limit the practitioner to document complex cases
Second element of access control
authentication - the act of verifying a claim of identity, CMS states "verify that a person or entity seeking access to electronic health information is the one claimed and is authorized to access such information"
Medical transcription
automated computer medical dictation (or voice capture) systems for dictating reports (clinical history, physical examination, consultation report, operative report, discharge summary, pathology reports, and radiology reports) It is stored in either tape or disk format and retrieved by the transcriptionists, typed or stored electronically in the EHR. The role of medical transcriptionist is that of a language editor.
Which of the following is a disadvantage of alphabetic filing? a. Easy to train new personnel to file b. Uneven expansion of file shelves or cabinets c. Ease of creation d. No reliance on an index or authority file
b. Uneven expansion of file shelves or cabinets
Data quality of EHR
begins at the point of creation. Managing data input through good design of end-user interfaces increases the probability of quality data.
Functional Components of HIM Core Model (6)
- Data Capture, Validation, and Maintenance - Data/Information, Analysis, Transformation, and Decision Support -Health Information Resource Management and Innovation - Information Governance and Stewardship - Quality and Patient Safety
retrospective payment system
...type of fee for service reimbursement in which providers receive recompense after health services have been rendered
Some HIM functions that include review and analysis of the health record are in place to monitor the healthcare facility's compliance with The Joint Commission standards and include:
1. Record completion process: - monitoring delinquency rates. TJC has a Hospital Medical Record Statistics form which is used by most hospitals to monitor compliance with TJC's standards. -Monitoring timely completion of medical reports: - Monitoring health record completion: document authentication 2. Documentation: - Monitoring the use of abbreviations acronyms, and symbols 3. Confidentiality of information: -Monitoring access to protected health information after discharge 4, Access to patient records: - Storage and retrieval processes accessible for patient care.
Certification
1. The process by which a duly authorized body evaluates and recognizes an individual, institution, or educational program as meeting predetermined requirements 2. An evaluation performed to establish the extent to which a particular computer system, network design, or application implementation meets a prespecified set of requirements
EHR Certification requirement by the CMS
1. access control 2. authentication 3. Authorization
Which of the following paper weights would be the most durable for the medical record folder?
20
What would be the linear filing inch capacity for a shelving unit with 6 shelves, each measuring 36 inches?
216 inches
Data applications, data collection, data warehousing, data analysis
4 domains of data quality
For many plans, the health plan and the patient share costs on a(an) _____ percent arrangement? A. 50/50 B. 80/20 C. 90/10 D. 75/25
80/20
ORYX initiative
A Joint Commission on Accreditation of Healthcare Organization initiative that supports the integration of outcomes data and other performance measurement data into the accreditation process. Initiative is to promote comprehensive, continuous, data-driven accreditation process for healthcare facilities.
Stage of neoplasm
A classification of malignancies (cancers) according to the anatomic extent of the tumor, such as primary neoplasm, regional lymph nodes, and metastases.
International Classification of Diseases, Ninth Revisions, Clinical Modification (ICD-9-CM)
A classification system used in the United States to report morbidity and mortality information
Current Procedural Terminology (CPT)
A comprehensive, descriptive list of terms and numeric codes used for reporting diagnostic and therapeutic procedures and other medical services performed by physicians; published and updated annually by the American Medical Association
Systemized Nomenclature of Medicine Clinical Terminology (SNOMED CT)
A concept-based terminology consisting of more than 110,00 concepts with linkages to more than 180,000 terms with unique computer-readable codes.
What should be done when the HIM department's error or accuracy rate is deemed unacceptable?
A corrective action should be taken
Minimum Data Set (MDS) Version 3.0
A federally mandated standard assessment form that Medicare and/or Medicaid-certified nursing facilities must use to collect demographic and clinical data on nursing home residents. Used to develop care plans for residents and to document placement at the appropriate level of care.
Hospital Discharge Abstract Systems
A group of databases complied from aggregate data on all patients discharged from a hospital.
Advance directive
A legal, written document that describes the patient's preferences regarding future healthcare or stipulates the person who is authorized to make medical decisions in the event the patient is incapable of communicating his or her preferences
Disease Index
A list of diseases and conditions of patients sequenced according to the code numbers of the classification system in use. Considered patient-identifiable data
Problem list
A list of illnesses, injuries, and other factors that affect the health of an indi- vidual patient, usually identifying the time of occurrence or identification and resolution
Data Sets
A list of recommended data elements with uniform definitions that are relevant for a particular use, to turn data into information.
Case Definition
A method of determining criteria for cases that should be included in a registry.
What is overlay?
A patient is assigned another patient's medical record number comingling the medical information of both patient's resulting in problems in identifying what medical information belongs to which patient
Inpatient
A patient who is provided with room, board, and continuous general nursing services in an area of acute care facility where patients generally stay at least overnight.
False
A physical therapist documenting in the health record is an institutional health record user?
Clinical Decision support
A physician just received notification from an EHR system that a patient's lab test had a dangerously high value. This is an example of what kind of clinical tool?
Physician's orders
A physician's written or verbal instructions to the other caregivers involved in a patient's care
Accreditation Commission for Health Care (ACHC)
A private nonprofit accreditation organization offering accreditation services for home health, hospice, and alternate site healthcare such as infusion nursing, and home/durable medical equipment supplies
Software
A program that detects the hardware components of a computer system to perform the tasks required.
National Committee on Vital and Health Statistics (NCVHS)
A public policy advisory board that recommends policy to the National Center for Health Statistics and other health-related federal problems.
Primary Data Source
A record developed by healthcare professionals in the process of providing patient care.
International Classification of Diseases, Tenth Revisions, Procedure Coding System (ICD-10-PCS)
A separate procedure coding system that would replace ICD-9-CM, volume 3, intend to improve coding accuracy and efficiency, reduce training effort, and improve communication with physicians
Patient Self-Determination Act (PSDA)
A series of structured questions to be answered by patients to provide information to clinicians about their current health status
Discharge summary
A summary of the resident's stay at the long-term care facility that is used along with the postdischarge plan of care to provide continuity of care for the resi- dent upon discharge from the facility
Integrated health record
A system of health record organization in which all the paper forms are arranged in strict chronological order and mixed with forms created by different departments
Joint Commission
A system of health record organization in which all the paper forms are arranged in strict chronological order and mixed with forms created by different departments
This is a false statement as the information is used for other purposes such as analysis
A user of health records includes only care providers who document in the health record or refer to it for patient care.
Communities of Pracitce (CoP)
A web-based electronic network for ocmmunication among members of the American Health Information Management Association
Student Membership
AHIMA membership category for students enrolled in an AHIMA accredited or approved program
What reimbursement system is associated with the Medicare outpatient prospective payment system? A. APCs B. MS-DRGs C. RBRVS D. RUG-IV
APCs
Analog Computers
Accept input in continuous analog signal form, and output is obtained in the form of scaled graphs. They have low memory size and have fewer functions. They are very fast in processing, but output return is not very accurate.
Process that determines who is authorized to access patient information in the health record.
Access control: involves determining which individuals or groups should be granted access, what portions of the health record should be available and what right should be granted. Access cards are often used in combination with passwords or personal identification numbers (PINS) as a method of authenticating identity
Dashboards
Access to high-level information in addition to the ability to drill down to departmental-level data.
What number is assigned to a case when it is first entered in a cancer registry? A. Accession number B. Patient number C. Health record number D. Medical record number
Accession number
Maintenance and Evaluation Phase
Activities that ensure both the short and long term success of the information system.
UHDDS UACDS MDS DEEDS HEDIS OASIS RAP EMDS
Acute Inpatient Care Outpatient Services long-term care facilities emergency services health plans home health care long-term care facilities Emergency Services
Which of the following should be part of a comprehensive MPI maintenance program?
Advanced Person Search
The future role of the HIM professional is expected to change due to: a. Advances in technology b. Implementation of new clinical coding system c. Evolution of the EHR d. All of the above
All of these
Natural Languages
Allow users to speak in a more conversational way with the computer and are part of the expanding field of artificial intelligence (AI)
Which identification system is at a disadvantage when there are two patients with the same name?
Alphabetic
Health Information Management (HIM)
An allied health profession that is responisbel for ensuring the availibility, accuracy, and protection of the lcinical information that is needed to deliver healthcare services and to make appropriate healthcare-related decisions.
False
An auditor who is employed by Medicare is reviewing a health record for a mortality study. This auditor is an individual health record user.
Personal health record (PHR)
An electronic record of health-related information on an individual that conforms to nationally recognized interoperability standards and that can be drawn from multiple sources while being managed and controlled by the individual
DNV (Det Norske Veritas)
An independent international organization that began offer- ing hospital accreditation services in the United States in 2008
Certified Documentation Improvement Practitioner (*CDIP)
An individual who has achieved specialized skills in the cancer registry
Privacy
An individual's right to control access to his or her personal information is known as
American Correctional Association
An organization that developed basic accreditation standards for healthcare in correctional facilities
Fee schedules are updated by third-party payers A. Annually B. Monthly C. Semiannually D. Weekly
Annually
Wireless Networks
Any type of computer network that is not connected by cables of any kind.
"Loose" reports are health record forms that:
Are received by the HIM department and added to the health record after it has been processed.
Information Architecture (IA)
Art and science of organizing and labeling websites, intranets, online communities and software to support usability.
EHR reconciliation processes
As with paper-based and hybrid records, electronic health records require that the HIM professional verify that there is an EHR present in the system for every discharged patient and verification of reports.
In a paper-based system, individual health records are organized in a pre-established order. This process is called
Assembly
Communication Devices
Assist communications among different computers.
Protect the legal interests of the facility and its healthcare providers
Attorneys for healthcare organizations use the health record to
Which term verifies claim of identity?
Authentication
Right or permission given to an individual to use a computer resource or to use specific applications and access specific data; is also a set of actions that gives permission to an individual to perform specific functions such as view, write, edit, delete, or execute tasks
Authorization - authorization software referred to as access control matrix.
Which of the following administrative documents provides information on the patient's desires for healthcare for use if he/she is incapacitated? A. Advance directive B. Patient's bill of rights C. Notice of privacy practices D. Authorization for release of information
Authorization for release of information
Information System (IS)
Automated system that uses computer hardware and software to record, manipulate, store, recover, and disseminate data.
Activities of daily living (ADL)
Basic activities of self-care, including grooming, bathing, ambulating, toileting, and eating.
Transmission Control Protocol/Internet Protocol (TCP/IP)
Basic communication language or protocol of the Internet.
Column/Field
Basic fact such as LAST_NAME, FIRST_NAME, DOB, RACE.
A patient's legal status, complaints of others regarding the patient, and reports of restraints or seclusion would be found most frequently in which type of health record? A. Rehabilitative care B. Ambulatory care C. Behavioral health D. Personal health
Behavioral health
Which of the following is an example of how an internal user utilizes secondary data? A. State infectious disease reporting B. Birth certificates C. Death certificates D. Benchmarking with other facilities
Benchmarking with other facilities
The expectation that personal information shared by an individual with a healthcare provider during the course of care will be used only for its intended purpose
Best describes the concept of confidentiality
Which group focuses on accreditation of rehabilitation programs and services? A. CARF B. AOA C. AAAHC D. HFAP
CARF
A healthcare program for dependents and survivors of permanently and totally disabled veterans: A. CHAMPUS B. CHAMPVA C. IHS D. TRICARE
CHAMPVA
The government agency that administers the Medicaid and Medicare programs is: A. HCFA B. DHHS C. CMS D. SSA
CMS
False
CMS uses data to accredit hospitals?
What are the regulatory agencies regarding legal health records?
CMS, federal regulations, state laws, and standards of accrediting agencies such as the Joint Commission, as well as the policies of the healthcare providers set the standards.
Minicomputers
Can support hundreds of connected users at the same time via terminals consisting of a keyboard and a video screen. Cheaper than mainframes.
CAAs
Care area assessments
Diabetes Registries
Cases of patients with diabetes for the purpose of assistance in managing care as well as for research.
CMS
Centers for Medicare and Medicaid Services
Medicaid eligibility standards are established by: A. Centers for Medicare and Medicaid Services B. Medicare C. Individual states D. Federal government
Centers for Medicare and Medicaid Services
Assigning ICD-9-CM and CPT codes to the diagnosis and procedures documented in the medical record is called:
Clinical coding
Birth Defects Registries
Collect information on newborns with birth defects.
Objective Evaluation
Collecting facts, figures, and measurements.
Database Management System (DBMS)
Collection of computer programs that controls the creation, maintenance, and use of a database, Important purpose is to maintain the data definitions (data dictionary) for all the data elements in the database.
Mesh Topology
Combines characteristics of bus, ring, and the star topologies, but allows for redundant routes for data transfer.
Objective-relational Database
Combines the best of the relational and object-oriented databases. Uses both traditional data types (such as currency, integers, and strings) and advanced data types (such as graphics, movies, audio and so on).
CARF
Commission on Accreditation of Rehabilitation Facilities
Histocompatibility
Compatibility of donor and recipient tissues
Comprehensiveness
Completeness.
Component state associations (CDAs)
Component state associations are part of the volunteer structure of AHIMA and are organized in every state, the District of Columbia, and the Commonwealth of Puerto Rico. The purpose of each compoenet state assiociation shall be to promote the mission and purpose of AHIMA in its state.
Turnkey Systems
Computer application that may be purchased from a vendor and installed without modification or further development by the user organization.
CPR
Computer-based patient record
A quantitative review of the health record for missing reports and signatures that occurs when the patient is in the hospital is referred to as a _______ review.
Concurrent
System Software
Conductor for all the hardware components and the application software.
Local-Area Networks (LAN)
Connects computers in a relatively small area.
Wide-Area Networks (WAN)
Connects devices across a large geographical area. Often simply consists of two or more LANs connected by telephone lines.
Operating System
Consists of the master programs, called the supervisor, that manage the basic operations of the computer.
Hybrid Computers
Contain both the digital and analog components. Users can process both the continuous (analog) and discrete (digital) data.
Data
Create the message that is transferred from the transmitter to the receiver as electrical pulses.
Which of the following types of organizations is not reimbursed under the outpatient prospective payment system? A. Partial hospitalization facilities B. Critical access hospitals C. Hospital outpatient departments D. Outpatient dialysis centers
Critical access hospitals
The prospective payment system implemented in 1983 is referred to as: A. APC B. DRG C. OPPS D. URC
DRG
National Hospital Care Survey
Data abstracted manually from a sample of acute care discharged inpatient records or obtained from state or other discharge databases.
Input
Data entered into a hospital system.
Transparency
Degree to which patients included in secondary data sets are aware of their inclusion.
A health record with deficiencies that is not complete within the timeframe specified in the medical staff rules and regulations is called a(n) _________ record.
Delinquent
What are the patient data such as name, age, address, and so on called? A. Demographic data B. Secondary data C. Aggregate data D. Identification data
Demographic data
Subjective, objective, assessment, plan (SOAP)
Documentation method that refers to how each progress note contains documentation relative to subjective observations, objec- tive observations, assessments, and plans
Transfer record
Documentation method that refers to how each progress note contains documentation relative to subjective observations, objec- tive observations, assessments, and plans
Physical examination report
Documentation of a physician's assessment of a patient's body systems
Continuity of Care Record (CCR)
Documentation of care delivery from one healthcare experience to another.
Use Case Diagram
Documents the functions of a system from the user's point of view.
They have a built in access control mechanism
Does not pertain to paper-based health records
Ring Topology
Each device is connected to the network in a closed loop or ring. Each machine is identified by a unique address.
Star Topology
Each machine is connected to a central hub.
What is used to check the quality of data entered into an information system? A. Edits B. Interrater reliability C. Audit trail D. Validity
Edits
Phase III of Clinical Trial
Effectiveness and side effects and make comparisons to other available treatment in larger populations.
Data Confidentiality
Efforts to guarantee the privacy of personal health information.
EHR
Electronic health record
EMR
Electronic medical record
A definition of what constitutes a record, recording where each component is located, and noting dates of format changes are particularly important in: A. Electronic records B. Integrated records C. Paper records D. Hybrid records
Electronic records
Specific performance expectations and/or structures and processes that provide detailed information for each Joint Commission standard are called:
Elements of Performance
Which type of health record contains information about care provided prior to arrival at a healthcare setting and documentation of care provided to stabilize the patient? A. Ambulatory care B. Emergency care C. Long-term care D. Rehabilitative care
Emergency care
Phase II of Clinical Trial
Emphasis is on determining the treatment's effectiveness and further investigating safety.
Network Protocols
Enable computers on the network to communicate with each other.
Education and Reference Software
Encyclopedias, anatomy atlases, and library searches.
Structure and content standards
Establish and provide clear and uniform definitions of the data elements to be included in EHR systems. They specify the type of data to be collected in each data field and the attributes and values of each data field.
Transaction-Processing System (TPS)
Example of an operations support system. Computer-based information system that keeps track of an organization's business transactions through inputs and outputs. Examples: patient admissions, employee time cards, and supply purchases.
Secondary data sources
Facility-specific indexes Registries
Supercomputers
Fastest and highest-capacity machines built today. Used in large-scale activities such as weather forecasting and mathematical research.
Microcomputers Personal Computers (PCs)
Fastest-growing type of computer today. They come in a variety of sizes, including desktop, laptop, palmtop, and pen-based.
Which agency/program provides federal employees injured in the performance of duty with workers' compensation benefits? A. Federal Employees' Compensation Act (FECA) B. Center for Medicare and Medicaid Services C. Tricare D. CHAMPVA
Federal Employees' Compensation Act (FECA)
National Center for Health Statistics (NCHS)
Federal agency responsible for collecting and disseminating information on health services utilization and the health status of the population in the United States.
ASTM International
Formerly known as the American Society for Testing and Materials, a system of standards developed primarily for various EHR management processes.
Association for Healthcare Documentation (AHDI)
Formerly the American Association for Medical Transcriptionist, the AHDI has a model curriculum for formal educational programs that includes the study of medical terminology, anatomy and physiology, medical science, operative procedures, instruments, supplies, laboratoyr values, reference use and research techniques, and English grammar
Cancer Registries
Founded in 1926 at Yale New Haven Hospital.
Health Level 7 (HL7)
Founded in 1987, not-for-profit, ANSI-accredited standards developing organization that provides comprehensive standards for the exchange, integration, sharing, and retrieving of electronic health information that supports patient care.
Very High-level Languages
Fourth generation of programming languages which includes report generators, query languages, data management languages, and application generators. These languages were developed to reduce programming effort, time, and costs.
Can free-text data be easily located, retrieved, and manipulated by a search engine?
Free-text data is undefined, unlimited, and unstructured. It is more difficult for a search engine to find, retrieve, and manipulate its data than structured text.
Screen Prototypes
Full-colored prototypes that illustrate the visual design of various page templates in a system.
Entertainment Software
Games and audio/video entertainment.
Utility Programs
Generally used to support, enhance, or expand existing programs in a computer system.
Data Flow Diagrams (DFD)
Graphical representation of the flow of data through an information system, modeling its process aspects.
In this HMO contract, providers usually agree to devote a fixed percentage of their practice time to the HMO: A. Group B. Independent practice C. Network D. Staff
Group
The computer software program that assigns appropriate MS-DRGs according to information provided for each episode of care is called a: A. Classification B. Catalog C. Register D. Grouper
Grouper
Healthcare Informatics Standards
Guidelines developed to standardize data throughout the healthcare industry (ex: developing uniform terminologies and vocabularies)
Protected Health Information (PHI)
HIPAA requires that healthcare facilities maintain an account of each required disclosure type of protected health information PHI.
Consultation report
Health record documentation that describes the findings and recom- mendations of consulting physicians
Which of the following is used to locate an electronic health record
Health record number
Data Timeliness
Healthcare data that is up-to-date. Data available within a time frame helpful to the user.
Which of the following is not a place where PACE services can be provided? A. Day healthcare centers B. Homes C. Hospitals D. Hospice
Hospice
PHR
I am a patient, my medical history including information from myself and my physicians is stored on the internet. This is an example of which of the following: A. Healthrecord, B. EHR, C. PHR, D. Data
Confidentiality
I just told my physician something embarrassing about myself. I told him because i expect him to use the information for my care only. This concept is called
Make decisions on healthcare reimbursement
I work for CMS how would I use the health record?
Research
I work for an organization that utilizes health record data to prove or disapprove hypotheses related to disease. I must work for what type of organization? A. Healthcare delivery B. Medical Review C. Research D. Education
The agency responsible for providing healthcare services to American Indians and Alaska natives is: A. CHAMPUS B. CHAMPVA C. IHS D. TRICARE
IHS
What tool is used to calculate the CMG? A. IRF-PAI B. OASIS C. MDS D. Grouper
IRF-PAI
Purpose of Data Sets
Identify the data elements that should be collected for each patient. Provide uniform definitions for common terms.
Which of the following electronic record technological capabilities would allow an x-ray to be sent to a physician in another state? A. Database management B. Image processing C. Text processing D. Vocabulary standards
Image processing
Phased Approach
Implementing portions of the new system over time instead of installing the entire system all at once.
The purpose of a physician query is to: A. Identify the MS-DRG B. Identify the principle diagnosis C. Improve documentation D. Increase reimbursement
Improve documentation
Continuity of Care Documentation (CCD)
In the exchange of information with other providers and the patient, the CCD combines the content that physicians have agreed should be included in patient referrals with a means to format the data for electronic transmission.
Secondary Storage Devices
Include a flash drive, hard disk drive, magnetic tape, and an optical disk drive. Drives may be external or internal.
In a paper-based system, the completion of the chart is monitored in a special area of the HIM department called the:
Incomplete record file
External Users
Individuals and institutions outside the facility. Secondary data is usually aggregated data and not patient-identifiable data.
Internal Users
Individuals located within the healthcare facility. Secondary data enables theses users to identify patterns and trends that are helpful in patient care, long-range planning, budgeting, and benchmarking with other facilities.
Vendor System
Information system developed by an outside company and sold to a variety of organizations.
Facility-specific system
Information system developed within the facility for its own use,
Executive Information System (EIS)
Information system intended to facilitate and support the information and decision-making needs of senior executives by providing easy access to both internal and external information relevant to meeting the strategic goals of an organization.
According to AHIMA, what can provide for quality discrete, structured data that are more easily manipulated and analyzed?
Input masks, lookup values, and validation rules
In an integrated health record, documentation by health professionals is organized: A. In sections by type of professional B. In sections by problem number C. Intermixed in date sequence D. Depends on facility policy
Intermixed in date sequence
Internet
International network of computer servers that provides individual users with communications channels and access to software and information repositories worldwide.
Application Service Providers (ASP) Cloud computing
Internet is used to access systems such as EHR, financial information systems, CPOEs, and other healthcare information systems software that are located at a remote site.
Subjective Evaluation
Involves finding out opinions.
Why is the MEDPAR File limited in terms of being used for research purposes? A. It only provides demographic data about patients. B. It only contains Medicare patients. C. It uses ICD-9-CM diagnoses and procedure codes. D. It breaks charges down by specific type of service.
It only contains Medicare patients
Extensible Markup Language
Key technology tool for enabling data sharing.
Input Devices
Keyboards; microphones; scanners; pointing devices such as mice, trackballs, light pens, and intelligent tables; sensors; and biometrics such as fingerprints, handprints, and iris scans.
Expert System (ES)
Knowledge system built from a set of rules applied to specific problems.
health record that is maintained as the business record and is the health record that may be disclosed to authorized users and for evidentiary purposes
Legal Health Record - facility must have a policy identifying the legal health record
Consent to treatment
Legal permission given by a patient or a patient's legal representa- tive to a healthcare provider that allows the provider to administer care and/or treatment or to perform surgery and/or other medical procedures
Which of the following terms refers to state or county regulations that healthcare facilities must meet to be permitted to provide care? A. Accreditation B. Bylaws C. Certification D. Licensure
Licensure
Handheld Devices
Lightweight mobile devices that provide special functions such as taking notes, organizing telephone numbers and addresses, and calendaring.
Integrated Services Digital Network (ISDN)
Lines that allow digital data to be transmitted through copper wire telephone lines.
Protocol
List of rules and procedures to be followed.
Phase IV of Clinical Trial
Look at the treatment after it has entered the market.
In healthcare organizations, what is the database that is used to locate the medical record number usually called?
MPI
What is the key to the identification and location of a patient's health record?
MPI
Barcodes
Machine-readable representations of data, typically dark ink on a light background.
Prospective payment systems were developed by CMS to: A. Increase healthcare access B. Manage Medicare and Medicaid costs C. Implement managed care programs D. Eliminate fee-for-service programs
Manage Medicare and Medicaid costs
What is the most important index used by the HIM department? What is it? What is its function?
Master Patient Index (MPI) and is the permanent record of every patient ever seen in the healthcare entity. The MPI functions as the primary guide to locating pertinent demographic data about the patient and his or her health record number. It is the initial point of documentation of the health record
The primary guide to locating a record in a numerical filing system is the
Master Patient Index MPI
Interrater Reliability
Measure of a research instrument's consistency in data collection when used by different abstractors.
Title XIX of the Social Security Act Amendment of 1965 is also known as: A. Medicare B. Medicaid C. Medigap D. SCHIP
Medicaid
This nonprofit organization contracts with physicians to manage their practices and owns clinical/business resources that are made available to participating physicians: A. Exclusive provider organization B. Group practice without walls C. Management service organization D. Medical foundation
Medical foundation
MS-DRG/ APC groupers
Medicare severity diagnosis related group APC groupers are software programs that help coders determine the appropriate ambulatory payment classification for outpatient encounters.
Autodialing System
Method used to automatically call and remind patients of upcoming appointments.
Case Finding
Method used to identify the patients who have been seen and/or treated in the facility for the particular disease or condition of interest to the registry.
MDS
Minimum Data Set
What type of paper-based storage conserves floor space by eliminating all but one or two aisles?
Mobile filing units
Facility-specific Indexes
Most long-standing secondary data sources. Enable health records to be located by diagnosis, procedure, or physician.
In this model, healthcare services are contracted with two or more multispecialty group practices instead of just one: A. Group B. Independent practice C. Network D. Staff
Network
In a paper-based system, the HIM department routinely delivers health records to:
Nursing units
What data set is used for patient assessments by the home health prospective payment system? A. HEDIS B. OASIS-C C. RAI D. UHDDS
OASIS-C
The essential elements of a Corporate Compliance Program are defined by: A. CMS B. HIPAA C. Medicare D. OIG
OIG
Unified Modeling Language (UML)
Object-oriented modeling language that assists in the documentation of a software project by specifying, visualizing, modifying, constructing, and documenting the artifacts of a system under development.
Office of the National Coordinator of Health Information Technology (ONC)
Office that provides leadership for the development and implementation of an interoperable health information technology infrastructure nationwide to improve healthcare quality and delivery.
What can function as a MPI?
Often the patient registration system aka registration, admission, discharge, and transfer system (R-ADT) functions as the MPI
Bus Topology
Older topology where each computer is connected to a common backbone or trunk through some kind of connector.
Which of the following is an advantage of a centralized unit filing system?
One location in which to look for records
Digital Computers
Operates by counting numbers or digits and gives output in digital form. Represents data in digital signals 0 and 1 and then processes it using arithmetic and logical operations. They give accurate results, they posses high-speed data processing, they can store large amounts of data, they are easy to program and use, and finally, they consume low energy.
If one needed to know the number of C-sections performed by a specific obstetrician, which of the following indices would be used to identify the cases?
Operation index
Data Base Management
Oracle, SQL Server, Sybase, and Access.
Direct Cutover Approach
Organization stops using the old system and starts the new one on a specific date.
A functionality of the electronic health record that allows patients access to their protected health information (for example, lab results) is:
Patient Portal
PSDA
Patient Self-Determination Act
PAI
Patient assessment instrument
Health Information Exchanges (HIEs)
Patient care data seamlessly transferred to where they are needed, at the time they are needed, and to who needs them,
True
Patient care managers are individual users of health records.
Which of the following patients qualify for a LUPA? A. Patient had 10 visits in the 60-day period. B. Patient had 3 visits in the 60-day period. C. Patient had 4 visits in the 60-day period. D. Patient had 5 visits in the 60-day period.
Patient had 3 visits in the 60-day period.
In which department/unit does the health record typically begin?
Patient registration
A growth and development record may be found in what type of record? A. Rehabilitative care B. Pediatric C. Behavioral health D. Obstetric
Pediatric
AHIMA's recommended retention standards
Permanently: Master Patient Index (MPI), Register of Births, Register of Deaths, and Register of surgical procedures 10 Years: Disease Index, Operative Index, and Physician index 10 Years after the age of majority: Fetal heart monitor records 10 Years after the most recent encounter: Patient health/medical records (adults) 5 Years: Diagnostic images (such as x-ray film) (adults) 5 Years after the age of majority: Diagnostic images (such as x-ray film) (Minors) Age of majority plus statue of limitations: Patient health/medical records (Minors)
Medical staff privileges
Permission granted to provide clinical services in a healthcare facility based on the credentials of the individual and limited to a specific scope of practice
PHR
Personal health record
RIP Steps
Planning, Design, Building, and Implementation.
Statements that describe general guidelines that direct behavior or direct or constrain decision making are called:
Policies
Version control of documents in the EHR requires:
Policies and procedures to control which version(s) is displayed.
Step by step instructions on how to complete a specific task are called:
Procedures
Abstracting
Process of extracting information from a document to create a brief summary of a patient's illness, treatment, and outcome.
Strategic Information Systems Planning
Process of identifying and assigning priorities to the various upgrades and changes that might be made in an organization's ISs.
Data Mining
Process that identifies patterns and relationships by searching through large amounts of data. Used to identify methods for cutting healthcare costs, suggest more appropriate medical treatments, and predict medical outcomes.
Good Database Design
Process that involves a team of individuals who have good relational database knowledge and extensive technical database design expertise.
Specialty Software
Programs designed for a specific purpose.
HIT Policy Committee (HITPC)
Provides recommendations to the National Coordinator on a policy framework for the development and adoption of a nationwide health information technology infrastructure that permits the electronic exchange and use of health information as in consistent with Federal Health IT Strategic Plan and that includes recommendations on the areas in which standards, implementation specifications, and certification criteria are needed.
What reimbursement system utilizes the Medicare fee schedule? A. APCs B. MS-DRGs C. RBRVS D. RUG-IV
RBRVS
EHR RIP
Rapid implementation planning process, systemic approach that helps to establish their EHR objectives, translate them to functional and technical requirements, and identify all resources needed to implement an EHR.
What facilitates efficiency, accuracy, and completeness of the health record?
Record Processing
Which of the typical HIM functions assist in monitoring and compliance of the health care facility with Joint Commission standards?
Record Processing
A chronological listing of data is called a/an?
Registry
Facility-based registries
Registry that includes only cases from a particular type of healthcare facility, such as a hospital or clinic.
Reviewing requests for health record copies and determining if they are valid is part of what function within the HIM dept?
Release of Information (ROI) function
Data consistency
Reliable data
MedWatch
Reporting system that alerts health professionals and the public of safety alerts and medical device recalls.
Which of the following is a request from a clinical area to charge out a health record?
Requisition
Health Services Research
Research concerning healthcare delivery systems, including organization and delivery and care effectiveness and efficiency.
Clinical Trial
Research project in which new treatments and tests are investigated to determine whether they are safe and effective.
Phase I of Clinical Trial
Research the safety of the treatment in a small group of people.
Reviewing the record for deficiencies after the patient is discharged from the hospital is an example of what type of review?
Retrospective
What microfilm format is inefficient when patients have multiple admissions on microfilm?
Roll
Which type of microfilm does not allow for a unit record to be maintained?
Roll microfilm
Parallel Approach
Running both old and new systems until the managers and staff are confident that the new system works.
Personal Database Management System
Runs on a client; used for small projects such as strong contact information.
Assembly Languages
Second generation, assembly language, uses a standard set of abbreviations to replace some of the ones and zeros of machine language. Usually defined by the hardware manufacturer and therefore are not portable to different computers.
In which numbering system does a patient admitted to a healthcare facility on three different occasions receive three different health record numbers?
Serial
Which numbering systems is best for maintaining the encounters of a patient together?
Serial-Unit
Features of Screen design:
Should be evaluated for features that will contribute to the capturing of quality health data and will provide ease of use, which in turn help to provide quality data. -Clear navigational buttons - direct the user to the next step in the documentation process and buttons to view the previous screen are imperative to assuring the user can use the system with ease. - Clear labeling of buttons and data fields - Limiting the use of abbreviations on buttons and data fields - Consistent location on the screen of navigation buttons - Built-in alerts to notify the user of possible errors - Availability of references at the appropriate data field - Prompt for more information where appropriate -checks for warning signs or errors
Computerized physician/provider -order entry
Since we implemented a new technology, we have eliminated lost orders and problems with legibility. What technology are we using?
Application Software
Software designed to assist a user in performing either a single task or multiple, related tasks.
Language Translator
Software that translates a program written by a programmer in a language such as C++ into machine language, which the computer can understand
Premiums are paid directly to this type of HMO, and services are usually provided within corporate facilities: A. Group B. Independent practice C. Network D. Staff
Staff
Graphic User Interface (GUI)
Style of computer interface in which typed commands are replaced by images that represent tasks.
Extranet
System of connections of private Internet networks outside an organization's firewall that uses Internet technology to enable collaborative applications among enterprises.
Nationwide Health Information Network (NHIN)
System that links various healthcare information systems together, allowing patients, physicians, healthcare institutions, and other entities nationwide to share clinical information privately and securely.
Colaborative Stage Data Set
System that uses algorithms to describe how far a cancer has spread.
deemed status
TJC accredited hospitals are also deemed to be in compliance with the Medicare Conditions of Participation. - Medicare makes random surveys as well
Which filing system is considered to be the most efficient?
Terminal-digit
One of the most sought after accreditation distinction by healthcare facilities is offered by the:
The Joint Commission
Which of these accreditation organizations provides standards for the widest variety of healthcare facilities? A. American Correctional Association B. The Joint Commission C. Accreditation Commission for Health Care D. American Osteopathic Association
The Joint Commission
What groups have established the standards for health record documentation?
The Joint Commission (TJC) and state licensing bodies as well as Medicare Conditions of Participation (MCoP), National Committee for Quality Assurance (NCQA), American Accreditation Health Care Commission/Utilization Review Accreditation Commission, American Osteopathic Association, Commission on Accrediitation of Rehabilitation Facilities, Health Accreditation Program of the National League of Nursing, College of American Pathologists, American Association of Blood Banks, American College of Surgeons, Accreditation Association for Ambulatory Health Care, and American Medical Accreditation Program. The Joint Commission offers an accreditation program for hospitals and other healthcare orgs based on pre-established accreditation standards.
This is a false statement as the PHR is controlled by the patient and the EHR is conttolled by the care providers
The PHR and EHR are synonyms
World Health Organization
The United Nations specialized agency for health, established on April 7, 1948, with the objective, as set out in its constitution, of the attainment by all peoples of the highest possible levels of health; responsible for the International Statistical Classification of Disease & Related Health Problems (ICD-10)
Conditions of Participation
The administrative and operational guidelines and regula- tions under which facilities are allowed to take part in the Medicare and Medicaid pro- grams; published by the Centers for Medicare and Medicaid Services, a federal agency under the Department of Health and Human Services; also called Conditions for Coverage
False. The health record documents the care provided by healthcare professionals
The health record documents services provided by allied health professionals and a patient's family
False
The lab test "hemoglobin:14.6 gm/110 mL is considered information.
American Association of Medical Record Librarians (AAMRL)
The name adopted by the ASsociation of Record LIbrarians of North America in 1944 precursor of the American Health Information Management Association
Incidence
The number of new cases of a specific disease.
International Classification of Diseases, Tenth Revisions, Clinical Modification (ICD-10-CM)
The planned replacement for ICD-9-CM, volumes 1 & 2, developed to contain more codes and allow greater specificity.
False
The primary purposes of the health record are associated directly with the provision of patient care services as well as the documentation of the patient's health status
Patient's bill of rights
The protections afforded to individuals who are undergoing medi- cal procedures in hospitals or other healthcare facilities; also referred to as patient rights
Anesthesia report
The report that notes any preoperative medication and response to it, the anesthesia administered with dose and method of administration, the duration of administration, the patient's vital signs while under anesthesia, and any additional prod- ucts given the patient during a procedure
Data Steward
The responsibilities and accountabilities associated with managing, collecting, viewing, storing, sharing, disclosing, or otherwise making use of personal health information.
American College of Surgeons (ACS)
The scientific and educational association of surgeons formed to improve the quality of surgical care by setting high standards for surgical educaiton and practice
The American College of Surgeons (ACS) Commission on Cancer
The scientific and educational association of surgeons formed to improve the quality of surgical care by setting high standards for surgical education and practice.
Chief Information Officer (CIO)
The senior manager appointed by a governing board to direct an organization's overall management.
Data Consistency
The value of the data should be reliable and the same across applications
Interface
The zone between different computer systems across which users want to pass information (for example, a computer program written to exchange information between systems or the graphic display of an application program designed to make the program easier to use)
Support for research
This is a secondary purpose of the health record
What is the goal of the health record system?
To ensure that accurate information is available to authorized users to support quality patient care.
True or False: The abbreviation used to describe the electronic transfer of information such as a claims submission is EDI.
True
True or False: The basis for prosecuting healthcare fraud and abuse is the Federal False Compliance Act.
True
True or False: The federal Office of the Inspector General established compliance plans for the healthcare industry.
True
True or False: Data quality begins at the point of creation
True
An accrediting organization is awarded deemed status by Medicare for one of its programs. This means that facilities receiving accreditation under its guidelines do not need to: A. Meet licensure standards B. Undergo Medicare certification surveys C. Undergo accreditation surveys D. Meet Medicare certification standards
Undergo Medicare certification surveys
Key Field
Uniquely identifies each row in a table.
Data
We had 324 Medicare patients last moth. This statement represents which of the following A. Information, B.Data, C. Content of the PHR, D. Patient-specific information
Generate a report to be used in performance improvement
Which is a secondary purpose of the health record?
All of the above
Which of the following is an advantage offered by computer-based clinical decision support tools? A. They give physicians instant access to pharmaceutical formularies, referral databases, and reference literature. B. They review structured electronic data and alert practitioners to out-of-range laboratory values or dangerous trends. C. They recall relevant diagnostic criteria and treatment options on the basis of data in the healthj record and thus support physicians as they consider diagnostic and treatment alternatives D. All of the above
Insurance that covers healthcare costs and lost income associated with work-related injuries is called: A. CHAMPVA B. Medicare C. Medicaid D.Workers' compensation
Workers' compensation
The National Cancer Registrars Association (NCRA)
Works with colleges to develop formal education programs for cancer registrars.
National Library of Medicine
World's largest medical library and a branch of the National Institutes of Health.
data comprehensiveness
a characteristic of data that includes every required data element
registry
chronological listing of data
amendments
clarification made to the health information after the original documentation has been final signed by the provider. Date, time, signed and attach to the original document that it is amending.
cost outlier
exceptionally high costs associated with inpatient care when compared with other cases in teh same diagnosis related group
information
factual data that have been collected, combined, analyzed, interpreted, and/or converted into a form that can be used for a specific purpose
Who governs the release of health record information?
federal regulations such as the Health Insurance Portability and Accountability Act (HIPPA) and state laws. To comply with HIPPA standards, a healthcare facility MUST maintain a record that accounts for all disclosures from the health record.
index
guide that serves as a pointer or indicator to locate something
general direction about the design of the form
guideline
Where should the process for checking patient records be located?
in the facility's charting policies and procedures
What is the foundation on which access control is based?
includes: identification, authentication, and authorization. Basic building block is identification usually performed through the user name and authorization
active membership
individuals intereseted in the AHIMA purpose and willing to abide by the Code ofEthics are eligible for active membership; active members in good standing shall be entitled to all membership privileges, including the right to vote.
Resequencing
involves moving a document from one place to another within the same episode of care. No annotation is needed.
Revenue Cycle Management
is a system that involves several processes working together to ensure that the healthcare facility is properly reimbursed for the services provided.
NONREPUDIATION measures
limit an EHR's user's ability to deny (repudiate) the origination, receipt, or authorization of a data exchange by that user" (ie signatures as example)
Complex case entries
may require the physician to use free text to adequately document a patient's condition. Free text is unstructured data and limits the facility's ability to report data.
Quality Management 3 fundamental tasks
measurement, assessment and improvement
When searching for a patient's record, what data elements can be used?
medical record or billing number, date of birth, or social security number.
Unit numbering system
most commonly used in large facilities. Patient receives a unique number on his first admission and the same number is used for subsequent encounters. Method most commonly used as the unique identifier in the EHR environment.
What language is behind the CAC engine
natural language processing (NLP) it analyzes text and extracts implied facts as coded data. The assigned codes are reviewed by the medical coding professional to assure the accuracy of the CAC
diagnostic codes
numeric or alphanumeric characters used to classify and report diseases, conditions, and injuries
Purged records
old records are removed from the file area. Purged records are often microfilmed, sent to off-site storage facilities or scanned.
Problem-oriented health record format
patient record in which clinical problems are defined an documented individually
Maintenance of destruction documentation
permanently - These are called certificates of destruction.
HIM is rapidly changing due to?
provisions mandated by the American Recovery and Reinvestment Act (ARRA) for the implementation of the electronic health record by 2014
Data applications
purpose for which data are collected
retrospective review
quantitative analysis is completed the day following the patient's discharge from the hospital.
review and analyze to a certain that no missing reports, forms, or required signatures and that all documents contain the patient's name and health record number - review for deficiencies called:
quantitative analysis or record content review
fixed rules that must be followed for every form
standards
HIMs most important functions
storage and retrieval of patient information. Additional functions managed: Research and statistics, Cancer and/or trauma registries, and Birth certificate completion
What are the most fundamental responsibilities of most HIM departments?
storage and retrieval, record processing, record completion, transcription, release of information (ROI), and clinical coding
interoperability
the ability, generally by adoption of standards, of systems to work together
data
the dates, numbers, images, symbols, letters, and words that represent basic facts and observations about people, processes, measurements, and conditions
data accuracy
the extent to which data are free of identifiable errors, ensures data have the correct value, are valid, and attached to the correct patient record
data relevancy
the extent to which healthcare related data are useful for the purpose for which they were collected
civilian health and medical program veterans affairs (CHAMPVA)
the federal healthcare benefits program for dependents of veteran rated by th eVeterans Administration as having a total and permanent disability, fo rsurvivors of veterans who died from VA-rated service connected conditions or who were rated permanently and toatlly disabled at the time of death from a VA rated service connected condition, and for survivors of persons who died in the line of duty
blue cross and blue shield (BC/BS)
the first prepaid healthcare plans in the United States;
Coding specialist
the healthcare worker responsible for assigning numeric or alphanumeric codes to diagnostic or procedural statements
security
the means to control access and protect information from accidental or intentional disclosure to unauthorized persons and from unauthorized alteration, destrucitno, or loss 2. the physical protection of facilities and equipment from theft, damage, or unauthorized access; collectively, the policies, procedures, and safeguards designed to protect systems, and control access to the content of these systems
procedural codes
the numeric or alphanumeric characters used to classify and report the medical procedures and services performed for patients
auditing
the performance of internal and/or external reviews to identify variations from established baselines
Certification
the process by which a duly authorized body evaluates and recognizes an individual, institution, or educational program as meeting predetermined requirements 2. an evaluation performed to established the extent to which a particular computer syste, network design, or application implementation meets a prespecified set of requirements
abstracting
the process of extracting data from the health record and entering them into a computer database
Credentialing
the process of reviewing and validating the qualifications (degrees, licenses, and other credentials) of physicians and other licensed independent practitioers, for granting medical staff membership to provide patient care services
privacy
the quality or state of being hidden from, or undisturbed by, the observation or activities of other persons or freedom from unauthorized intrusion; in healthcare related contexts, the right of a patient to control disclosure of personal information
Functionality of EHR
varies depending on the system used. refers to features in the EHR that allow the user to maintain different versions of a document, track changes made to a document, lock a document from changes, and create user profiles that limit who may edit entries and so forth. The ability to unlock a record should be given to only a few individuals and typically this would be the health information manager. The HIM professional must track changes to the health record and assure appropriate follow-up in any source systems or other data repositories.
What controls which version of the document will be viewable within the health record?
version control - example one unsigned and one signed - documents must be flagged when an earlier version of a document exists and the date and time of the availability of each version of the document must be clearly documented.
Data accuracy (data validity)
Data that is correct
Physician Data Query (PDQ)
Database for cancer clinical trials.
Healthcare Integrity and Protection Data Bank (HIPDB)
Database maintained by the federal government to provide information on fraud-and-abuse findings against U.S. healthcare providers.
National Practitioner Data Bank (NPDB)
Database of medical malpractice payments, adverse licensure actions, and certain professional review actions (such as denial of medical staff privileges) taken by healthcare entities such as hospital against physicians, dentists, and other healthcare providers as well as private accrediting organizations and peer review organizations.
Destruction documentation:
Date of destruction Method of destruction Description of the disposed records Inclusive dates covered A statement that the records were destroyed in the normal course of business The signatures of the individuals supervising and witnessing the destruction
The amount of money that the patient is responsible for before the insurance kicks in is called the: A. Coinsurance B. Deductible C. Out-of-pocket expenses D. Indemnity
Deductible
Transmitter
Device that sends the information
Where does free-text data exist in the health record?
Dictated and transcribed medical reports are an example. Many advantages of manipulation of data that the EHR offers are lost when the health record is comprised of large amounts of unstructured data.
Peripherals
Different pieces of hardware that are connected to CPUs to make them more functional and user-friendly. Input, processing and memory, output, storage, and communications.
Which of the following concepts is applied when multiple surgical procedures are furnished during the same operative session? A. Bundling of services B. Outlier adjustment C. Pass-through payment D. Discounting of procedures
Discounting of procedures
examples of policies regarding amending, correcting, or deleting health record entries
- After a document or entry in a health record has a final signature on it, the only way to correct it is to add an addendum to the record. The addendum must have a separate signature, date, and time from the original entry. -The original version of the document in a corrected health record must be maintained. The version should be clearly indicated on the document. EX: reports should indicate, "Final Copy", "Preliminary Copy", or "final copy with corrections." -A health record should be locked from editing once the final signature has been applied. - The appearance of information added to the record to amend or correct it should be different than the original entry (that is, it may be a different color, italic, or bolded).
Features of Navigation design:
- All controls should be clear and placed in an intuitive location on the screen - Use neutral colors and limit highlighting, flashing, and so forth to reduce eye fatigue - Limit choices and label commands -Provide undo buttons to make mistakes easy to override - Use consistent grammar and terminology - Provide a confirmation message for any critical function (such as deleting a file)
Features of Output design
- Minimize the number of clicks needed to reach data or a specific screen - Combine data into a single, organized menu to eliminate layers of screens. The system should also mark required data fields so that the EHR user cannot proceed to the next screen without completing required information.
present on admission (POA)
...a condition preent at the time of inpatient admission
Features of Data validation
- Perform a completeness check to ensure that all required data have be entered - Perform a format check to ensure that data are the right type (Numeric, alphabetic, and so on) - Perform a range check to ensure that numeric data are in the correct range. - Perform a consistency check to ensure that combinations of data are correct - Perform a database check to compare data against a database or file to ensure data are correct as entered.
EHR selection features
- Screen Design -Navigation Design - Input Design -Data validation -Output Design
Features of Input design:
- Simplify data collection - Sequence data input to follow workflow - Provide a title for each screen - Minimize keystrokes by using pop-up menus - Use text boxes to enter text - Use a number box to enter numbers - Use a selection box to allow the user to select a value from a predefined list: check boxes (multiple selections), radio buttons (single selections), on-screen list boxes (drop down list boxes or combo boxes)
Monitoring Quality Control of Medical Transcriptions
- To monitor transcription accuracy, a sample of the transcriptionists' reports can be checked for wrong terms, misspelled words, incorrect format, and/or grammatical errors. The number of errors found is noted, and an error or accuracy rate is determined and compared against an established standard. - Transcription turnaround time also can be monitored to determine whether reports are being transcribed within the expected time frame set in a standard. Most dictation/transcription computer management systems track the date and time reports are dictate and transcribed. A report indicating dictation and transcription time and date can be used to determine turnaround time.
Minimal amount of data required for a disease or operation index includes: (8)
- principal diagnosis and relevant secondary diagnosis - associated procedures - patient's health record number -patient's gender, age, and race - attending physician's code or name - the hospital service - the end result of hospitalization - dates of encounter (including admission and discharge for inpatients)
Capture of EHR data:
-Data are entered directly into the computer at the point of care - Paper documents are scanned and imaged -Other computer systems are interfaced with the EHR (laboratory, radiology) -Transcribed reports are electronically transmitted to the EHR
New roles most likely to evolve with technology
-HIM manager would have enterprise or facility wide responsibility for HIM. -Clinical Data Specialist perform data management functions in a variety of application areas including clinical coding, outcomes management, specialty registries, and research databases. -Patient Information Coordinator: perform new service roles that help consumers manage their personal health information, including personal health history management, ROI, managed care services, and information resources. -Data Quality Manager: perform functions involving formalized continuous quality improvement for data integrity throughout the enterprise -Data Resource Admin: responsible for the net generation of records and data management using media such as the CPR, data repository, and electronic warehousing. -Research and Decision Support Analyst: support senior management with information for decision making and strategy development. - Security Officer - manage the security of all electronically maintained information, including the promulgation of security requirements, policies and privilege systems and performance audits.
What are some specific risks to documentation integrity when using copy functionality?
-Inaccurate or outdated information that may adversely impact patient care, - Inability to identify the author or what they thought. - Inability to identify when the documentation was created. - Inability to accurately support or defend E/M codes for professional or technical billing notes. - Propagation of false information. - Internally inconsistent progress notes
Supervisory responsibilities associated with the management of the HIM functions
-Policy and Procedure Development: the foundation for management and supervision of employees in any dept. Policies are statements that describe general guidelines that direct behavior or direct and constrain decision making in the organization. Procedures are specific statements about how work is to be carried out. Step by step instructions on how to complete a specific task.
ARRA of 2009 - attributes
-Pres Obama -provides funds to promote the use of interoperable, certified health information technologies including EHR adoption. -provides financial assistance and incentives necessary for the transition to electronic health records. Beyond funding, the Office of the National Coordinator for Health Information Technology (ONC) a federal entity located within the Office of the Secretary for the US Department of Health and Human Services (HHS) ESTABLISHED THE STANDARDS.
group health insurance
...a prepaid medical plan that covers thehealthcare expenses of an organization's full time employees
Medigap
...a private insurance policy that supplements Medicare coverage
programs of all inclusive care for the elderly (PACE)
...
upcoding
...
payer of last resort (Medicaid)
...a Medicaid term that means that Medicare pays for the services provided to individuals enrolled in both Medicare and Medicaid until Medicare benefits are exhauseted and Medicaid benefits begin
resource based relative value sale (RBRVS)
...a Medicare reimbursement system implemented in 1992 to compensate physicians according to a fee schedule predicated on weights assigend on the basis of the resources required to provide the services
tricare prime
...a TRICARE progarm that provide the most comprehensive healthcare benefits at the lwoest cost of the three TRICARE options, in which military treatment facilities erve as the principal source of healthcare and aprimary care manager is assigned to each enrollee
tricare standard
...a TRICARE program that allows elegible beneficiaries to choose any physician or healthcare provider, which permits the most flexiblity but may be the most expensive
resource utilitzation groups, version IV (RUG-IV)
...a case mix adjusted classification system based on Minimum Data Set assessments and used by skilled nursing facilities
episode of care (EOC) reimbursement
...a category of payments mae as lump sums to providers for all healthcare services delivered to a patient for a specific illness and/or over a specified time period;
home health resource group (HHRG)
...a classification system with 80 hmoe health episode rates established to support the prospecitive reimbursement of covered home care and rehabilitation services provided to Medicare beneficiaries during 60 day episodes of care
current procedural terminology (CPT)
...a comprehensive, descriptive list of terms and numeric codes used for reporting diagnostic and therapeutic procedures and other medical services performed by physicians; published and jupdated annually by teh Americna Medical Association
DRG grouper
...a computer program that assigns inpatient cases to diagnosis-related groups an ddetermines the Medicare reimbursement rate
inpatient rehabilitation validation and entry (IRVEN)
...a computerized data entry system used by inpatient rehabilitation facilities
tricare extra
...a cost effective preferred provider network TRICARE option in which costs for healthcare are lower than fo the standard TRICARE program because a physician or medical specialist is selected from a network of civilian healthcare professionals whoparticipate in TRICARE Extra
medicare fee schedule (MFS)
...a feature of the resource-based relative value system that includes a complete list of the payments Medicare makes to physicians and other providers
civilian health andmedical program of teh uniformed services (CHAMPUS)
...a federal program providing supplementary civilian sector hospital and medical services beyond that which is available in military treatment facilities to military dependents, retirees, and their dependents, and certain other.
hospitalization insurance (HI) (Medicare Part A)
...a federal program that covers teh costs associated weith inpatient hospitalization as well as other healthcare services provided to Medicare beneficiaries
temporary assistance for Needy families (TANF)
...a federal program that provides states with grants to be spent on time limited cash assistance for low income families, generally limiting a family's lifetime cash welfare benefits to a maximum of five years and permitting states to impose other requirements.
patient protection and affordable care act
...a federal statue that was signed into law on March 23, 2010. along with the Health Care and Education Reconciliation Act of 2010, the Act is the product of the healthcare reform agenda of the Demoncratic 111th Congress and Obama administration
Medicare
...a federally funded health program estabished in 1965 to assist with the medical care costs of Americans 65 years and older as well as other individuals entitled to Social Security benefits owing to their disabilities
Minimum Data Set 3.0 (MDS)
...a federally mandated standard assessment form that Medicare and/or Medicaid certified nursing facilities must use to collect demographic and clincial data on nursing home residents.
chargemaster
...a financial manager form that contains information about the organization's charges for the healthcare services it provides to patients
global payment
...a form of reimbursmeent used for radiological and other procedures that ocmbines teh professional an dtechnical components of the procedures and disperses payments as lump sums to be distributed between the physician and the healthcare facility
medicare carrier
...a health plan that processes Part B claims for services by physicians and medical suppliers
inpatient psychiatric facility (IPF)
...a healthcare facility that offers spychiatric medical care on an inpatient basis; CMS established a prospective payment system for reimbursing these types of facilities using the current DRGs for inpatient hospitals
inpatient rehabilitation facility (IRF)
...a healthcare facility that specializes in providing services to patients who have suffered a disabling illness or injury in an effort to help them achieve or maintain their optimal level of functioning, self care and independence
nonparticipating providers
...a healthcare provider who didi not sign a participation agreement with Medicare and so is not obligated to accept assignment on Medicare claims
insured
...a holder of a health insurance policy
long term care hospital (LTCH)
...a hospital with an average length of stay of 25 days or more
fee schedule
...a list of healthcare services and procedures (usually CPT/HCPCS codes) and the charges associated with them develpoed by a third party payer to represent the approved payment levels for a gien insurance plan; also called table of allowances
preferred provider organization (PPO)
...a managed care arraqngement bassed ona contractual agreement between healthcare providers (professional and/or istitutional) an dto a defined population of enrollees at established fees that may or may not be a discount from usual and customary or reasonab le charges
National conversion factor (CF)
...a mathematical factor used to convert relative value units into monetary payments for services provided to Medicare beneficiaries
capitation
...a method of healthcare reimbursement in which an insurance carrier prepays a physician, hospital, or other healthcare provider a fixed amount for a given population without regard to the actual number or nature of healthcare services provided to the population
fee for service basis
...a method of reimbursment through which providers retrospectively receive payment based oneither billed charges for servicers provided or on an annually updated fee schedule
public assistance
...a monetary subsidy provided to financially needy individuals
relative value unit (RVU)
...a number asigned to a procedure that describes its difficulty and expense in relationship to other procedures
global surgery payment
...a payment made for surgical procedures that includes the provision of all healthcare servicesw, from the treatment decision through postoperatie patient care
packaging
...a payment under the Medicare outpatient prospective payment system that includes items such as anesthesia, supplies, certain drugs, and the use of recovery and observation rooms
skilled nursing facility prospective payment sysetm (SNF PPS)
...a per diem reimbursement system implemented in July 1998 for costs (routine, ancillary, and capital) associated with covered skilled nursing facility services furnished to Medicare Part A beneficiaries
external reviews (audits)
...a performance or quality reivew conducted by a third-party payer or consultant hired for the purpose
network provider
...a physician or another healthcare professional who is a member of a managed care network
National Committee for Quality Assurance (NCQA)
...a private, not for profit accreditation organization whose mission is to evaluate an dreport aon the quality of managed care organizations in the United States
voluntary disclosure program
...a progarm unveiled in 1998 by the Office of the Inspector General (OIG) that encourages healthcar providers to voluntarily report fraudulent conduct affecting Medicare, Medicaid, and other federal healthcare programs
home health agency (HHA)
...a program or organization that proivdes a blend of homebased medical and social services to homebound patients and their families for teh purpose of promoting, maintaining, or restroing health or of minimizing the effects of illness, injury, or disability
healthcare provider
...a provider of diagnostic, medical, and suargical care as well as the services or supplies related to the health of anindividual an dany other peson or organization that issues reimbursement claims or is paid for healthcare in the normal course of business
traditional fee for service reimbursement
...a reimbursement method involving third party payers who compenstae providers after the healthcare services have been delivered; payment is based on specific services provided to subscribers
National correct coding initiative (NCCI)
...a series of codes edits on Medicare Part B claims
healthcare effectiveness data and information set (HEDIS)
...a set of performance measures developed by the National Commission for Quality Assurance that are designed a provide purchasers and consumers of healthcare with the information they need to compare the performance of managed care plans.
outpatient code editor (OCE)
...a software program linked to the Correct Coding Initiative that applies a set of logical rules to determine whether various combinations of codes ar ecorrect and appropriately represent the servcies provided.
outcomes and assessment information set (OASIS)
...a standard core assessment data tool develped to measure the outcomes of adult patients receiving home health services under the Medicare and Medicaid programs
explanation of benefits (EOB)
...a statement issued to the insured and the healthcare provider by an insurer to explain the services provided, amounts billed, and payments made by a health plan
Medicare Summary Notice (MSN)
...a summary sent to the patient from Medicare that summarizes all services provided over a period of time with an explanation of benefits provided
integreated delivery system (IDS)
...a system that combines the financial and lcinicasl aspects of ehalthcare and uses a group of healthcare providers, selected on the basis of quality and cost management criteria, to furnish comprehensive health services across the continuum of care
partial hospitalization
...a term that refers to limited patients stays inteh hospital setting, typically as part foa transitional program to a less intense level of service
revenue codes
...a three or four digit number in the chargemaster that totals all items and their charges for printing on the form used for Medicare billing
resident assessment validation and entry (RAVEN)
...a type of data entry software develpoed by the Centers for Medicare and Medicaid Services for long-term care facilities and used to collect Minimum Data Set assessments and to transmit data to state databases
home assessment validation and entry (HAVEN)
...a type of data entry software used to collect Outcome an dAssessment Informatin Set (OASIS) data and then transmit them to state databases; imports and exports data in standard OASIS record format, maintains agency/patient/comployee information, enforces data integrity through rigorous edit checks, and provides comprehensive online help
staff model HMO
...a type of health maintenance that employs physicians to provide healthcare services to subscribers
group model HMO
...a type of health plan in which an HMO contracts with an independent multispecialty physician group to provide medical services to members of the plan
per member per month (PMPM)
...a type of manaed care arrangement by which providers are paid a fixed fee in exchange for supplying all of the healthcare services an enrollee needs for a specified period of time (usually one month but sometimes on year.
per patient per month (PPPM)
...a type of manaed care arrangement by which providers are paid a fixed fee in exchange for supplying all of the healthcare services an enrollee needs for a specified period of time (usually one month but sometimes on year.
group pracitce without walls (GPWW)
...a type of managed care contract that allows physicians to maintain their own offices and share adminstyrative services
point of service (POS) plan
...a type of managed care plan in which enrollees are encouraged to select healthcare providers forma network of providers under contract with the plan but are also allowed to select providers outside the network and pay a larger share of the cost
prospective payment system (PPS)
...a type of reimbursement system that is based on preset payment levels rather than actual charges billed after the service has been provided;
respite care
...a type or short term care provided during the day or overnight to idividuals in the home or institution to temporily relieve the family home caregiver
resident assessment instrument (RAI)
...a uniform assessment instrument deveoped by the Centers for Medicare and Medicaid Services to standardize the collection of skilled nursing facility patient data
indemity plans
...health insurance coverage provided in the form of cash payments to patients or providers
out of pocket expenses
...healthcare costs paid by the insured after which the insurer pays a percentage of covered expenses
diagnosis related groups (DRGs)
...a unit of case mix clasifications adopted by the federal government and some other payers as a prospective payment mechanism for hospital inpatients in which diseases aer placed into groups because realted diseases and treatments ten to consume similar amounts of heatlhcare resources and incur similar amounts of cost; in the Medicare and Medicaid programs, one of the more than 500 diagnostic classifications in which cases demonstrate similar resource consumption and lenght of stay patterms
supplemental medical insurance (SMI) (Medicare Part B)
...a voluntary medical insurance program that helps pay for physicians' services, medical services, an dsupplies not covered by Medicare Part A
premium
...amount of money that a plicyholder or certificate holder must periodically pay an insurer in return for healthcare coverage
payment status indicator (PSI)
...an alphabetic code assigned to CPT/HCPCS codes to indicate whether a service or procedure is to be reimbursed under the Medicare outpaiten prospective payment system
healthcare common procedure coding system (HCPCS)
...an alphanumeric classification system that identifies healthcare procedures, equipment, and supplies for claim submissionpurposes; the three levels are as follows I, Current Procedural Terminology coes, developed by the AMA; II, codes for equipment, supplies, and services not covered by Current Procedural Terminolgoy codes as well as modifiers, that can be used with all levels of codes, developed by CMS; and III (eliminated December 31, 2003, to comply with HIPAA), local codes developed by regional Medicare Part B carriers an dused to report physician's services and supplies to Medicare for reimbursment
low utilization payment adjustment (LUPA)
...an alternative (reduced) payment made to home health agencies instead of teh home health resource group reimbursement rate when a patient recieves fewer than four home care visits during a 60 day episode
Medicaid
...an entitlement program that oversees medical assistance for individuals and families with low incomes and limited resources; jointly funded between state and federal governments
remittance advice (RA)
...an explanation of payments made by third party payers
geographic practice cost index (GPCI)
...an index developed by the Centers for Medicare and Medicaid Services to measure the differences in resource costs among fee schedule areas compared to thenational average in teh three componenets of the relative value unit; physican work, practice expenses, and malpractice coverage.
policyholder
...an individual or entity that purchases healthcare insurance coverage
third party payer
...an insurance company that reimburses healthcare providers and/or patients for the delivery of medical services
physician hospital organization (PHO)
...an integreated delivery system formed by hospitals an dphysicians (usually through managed care contracts) that allows for cooperative activity but permits participants to retain some level of independence
hospice
...an interdisciplinary program of palliative care and supportive services that addresses the physical, spiritaul, social, and economic needs of terminally ill patients and their families
independent practice association (IPA)
...an open panel health maintenance organization that provides contract healthcare services to subscribers through independent pysicians who treat patients in their own offices; the HMO reimburses the IPA on a capitated basis; the IPA may reimburse the physicians on a fee for service or a capitated basis
medically needy option (Medicaid)
...an option in the Medicaid program that allows states to extend eligibility to persons who would be eligible for Medicaid under one of the mandatory or optional groups buyt whose income and/or resources fall above the eligibility level set by their state.
Integrated provider organization (IPO)
...an organization that manages the delivery of healthcare services provided by hospitals, physicians, (employees of the IPO), and other healthcare organizations
insurer
...an organiztion that pays healthcare expenses on behalf of its enrollees
management service organization (MSO)
...an organiztion, ususally owned by a group of physicians or a hospital, that provides adminstrative and support services to one or more physician group practices or small hospitals
employer based self insurance
...an umbrell term used to describe health plans that are funded directly by employers to provide coverage for their employees exclusively in which employers establish accounts to cover their employees' medical expenses and retain control over the funds but vear teh risk of paying claims greater than their estimates
categorically needy eligibility groups (Medicaid
...categories of individuals to whom states must provide coverage under the federal Medicaid program
health maintenance organization (HMO)
...entity that combines teh provision of healthcare insurance and the delivery of healthcare services, characterized by : 1. an organized healthcare delivery system to a geographic area, 2. a set of basic and supplemental health maintenance and treatment services, 3. voluntarily enrolled members, and 4. predetermined fixed, periodic prepayments for members' coverage
case mix group (CMG) relative weights
...factors that ccount fo rhte variance incost per discharge and resource utuilization among case mix groups
omnibus budget reconciliation act (OBRA)
...federal legislation passed in 1987 that required the Health Care Financing Adminstration ( now named the Centers for Medicare and Medicaid Services) to develop an assessment instrument (called the resident assessment instrument) to standardize the collection of patient data from skilled nursing facilities
state workers' compensation insurance funds
...funds that proivde a stable source of insurance coverage for work-realted illnesses and injuries and serve to protect employers from underwriting uncertainties by making it possibel to have continuing availability of workers' compensation coverage
exclusive provider organization (EPO)
...hybrid managed care organization that provides benefits to subscribers only when healthcare services are performed by network providers; sponsored by self-insured (self-funded) employers or associations and exhibits characteristics of both health maintenance organizations and preferred provider organizations
claim
...itemized statement of heatlhcare services and their costs provided by a hospital, physician's office, or other healthcare provider; submitted for reimbursement to the healthcare insurance plan by either the insured party or by the provider
medical foundation
...multipurpose, nonprofit service organization for physicians and other healthcare providres at the local and county level; as managed care organizatoins, they have established preferred provider organizations, exclusive provider organizations, and management service organizations with emphases on freedom of choice and preservation of the physician patient relationship
medicare administrative contractor (MAC)
...newly established contracting entities that will administer Medicare Part A and Part B as of 2011
medicare advantage
...optional managed care plan for Medicare beenficiaries who are entitled to Part and, enrolled in Part B, and live in an area with a plan/ types include health maintenance organization, point of service plan, preferred provider organization, and proivder sponsored organization.
recovery audit contractor (RAC)
...organization contracted to detect and correct improper payments inthe Medicare Fee for Service (FFS) Program
managed care
...paymnet method in which the third party payer has implemented some provisions to control the costs of heatlhcare while maintaining quality care 2. systematic merger of clinical, financial, and administrative processes to manage access, cost, and quaity of heatlhcare.
Major medical insurance
...prepaid healthcare benefits that include a high limit for msot types of medical expenses and usually require a large deductible and sometimes place limits on coverage and charges
precertification
...process of obtainign approval from a healthcare insurance company before receiving healthcare services
network model HMO
...program in which participating HMOs contract for services with one or more multispecialty group practices
hospital acquired condtions (HAC)
...select, responably preventable conditions for which hospitals do not receive additional payment when one of the conditions was not present on admission
case mix group
...the 97 function related groups into which inpatient rehabilitation facility discharges are classifed on the basis of the patient's level of impairment, age, comorbidities, functional ability, and other factors
outpatient prospective payment system (OPPS)
...the Medicare prospective payment system used for hospital based outpatient services and procedures that is predicated onteh assignment of ambulatory payment classifications
medicare severity diagnosis-related groups (MS-DRGs)
...the US government's 2007 revision of the DRG system, the MS-DRG system better accoutns for severity of illness and resource consumption
case mix index
...the average relative weight of all cases treated at a given facility ior by a given physician, which reflects the recource intensity or clinical severity fo a specific group in relation to the other groups int eh classification system; calculated by dividing the sum of the weights of diagnosis related groups for patients discharged during a given period divided by the total number of patients discharged
department of health and human services (HHS)
...the cabinet level federal agnecy that oversees all fo the health and human services related activities of the federal government and adminsters federal regulations
state children's health insurance program (SCHIP)
...the children's healthcare prgram im[plemented as part of the Balanced Budget Act of 1997;
veterans health administration
...the component of the U.S.Department of Veterans Affiars that implements the medical assistance program of the VA
principle diagnosis
...the disease or condition that wa present on admission, was the principal reason for admission, and received treatment or evalutaion during the hospital stay or visit.
centers for Medicare and Medcaid services (CMS)
...the division of the Department of Health and Human Services that is responsible for developing healthcare policy in the United States and for administereing the Medicare program and the federal port5ion of the Medicaid program
coordination of benefits (COB) transaction
...the electronic transmission of claims and /or payment information from a healthcare provider to a health plan for the purpose fo determining relative payment responsibilities
indian health service (IHS)
...the federal agnecy within the Department of Health and Human Services that is responsibel for providing federal healthcare services to American Indians and Alaska natives
tricare
...the federal healthcar program that provides coverage for the dependents fo armed forces personnel and for retirees receivign care outside military treatment facilities in which the federal government pays a percentage of the cost formerly known as teh Civilian Health and Medical Program of the Uniformed SErvices
tax equity and fiscal responsibility act of 1982 (TEFRA)
...the federal legislation that modified Medicare's retrospective reimbursement system for inpatient hospital stays by requiring implementation of diagnosis related groups and the acute care prospective paymenbt systm
social security act
...the federal legislation that originally established the Social Security program as well as unemployment compensation, and support for mothers and children, amended in 1965 to createthe Medicare and Medicaid programs
compliance program guidance
...the information provided by the Office of the Inspector General fo the Department of Health and Human Services to help healthcare organizations develop internal controls that promote adherence to applicable federal and state guidelines
fraud and abuse
...the intentional and mistaken misrepresentation of reimbursement claims submitted to government sponsored health programs
federal employees' compensation act (FECA)
...the legistlation enacted in 1916 to mandate workers' compensation for civilian federal employees, whose coverage includes lost wages, medical expenses, and survivors' benefits
workers' compensation
...the medical and income insurance coverage for certain employees in unusually hazardous jobs.
national uniform billing committee (NUBC)
...the national group responsible for identifying data elements and designing the CMS-1500
Primary care physician (PCP)
...the physiciabn who proivdes, supervises, and coordinates teh healthcare of a member and who manages referrals to other healthcare providers and utilization of healthcare services both inside and outside a managed care plan. 2. the physician who makes the initial diagnosis of a patient's medical condition
professional component (PC)
...the portion of a healthcare procedure performed by a physician 2. a term generally used in reference to the elements of radiological procedures performed by a physician
technical component (TC)
...the portion of radiological and othe rprocedures that is facility based or nonphysician based
unbundling
...the practice of using multiple codes to bill for the various individual steps in a singel procedure rather than using a single code that includes all of the steps of the comprehensive procedure
principle procedure
...the procedure preformed for the definitive treatment of a condition (as opposed to a procedure performed for diagnostic or exploratory purposes) or for care of a complication
hard coding
...the process of attaching a CPT/HCPCS code to a procedure located on teh facility's chargemaster so that the code will automatically be included ont he patient's bill
discharge planning
...the process of coordinating the activites related to the release of a pateitn when inpatient hospital care is no longer needed
compliance
...the process of establishing an organizational culture that promotes the prevention, detection, and resolution of instances of conduct that do not conform to federal, state, or private payer healthcare program requirements or thehealthcare organization's ehtical and business policies 2. the act of adhering to oficial requirements
home health prospecitive payment system HH PPS)
...the reimbursement system developed by the Centers for Medicare and Medicaid Services to cover home health services provided to Medicare beneficiaries
UB-04 (CMS-1450)
...the single standardized Medicare form for standardized uniform billing, scheduled for implementation in 2007 for hospital inpatients and outpatients; this form will also be used by the major third party payers and most hospitals
CMS-1500
...the universal insurance claim form developed and approved by the American Medical Association and teh Centers for Medicare and Medicaid Services; physicians use it to bill Medicare, Medicaid, and private insurers for services provided
major diagnostic category (MDC)
...under diagnosis related groups (DRGs), one of 25 categories based on single or multiple organ sysetms into which all disease and disorders relating to that system are classifeid
Work Flow of digital dictation
1 physician dictates a medical report and the transcriptionist transcribes the dictation into a structured medical report. 2. The transcribed reports are electronically transmitted to the EHR. The EDMS attaches an auto-signature deficiency and the transcribed report is then electronically routed to a physician work queue for signature.
Mortality
1) A term referring to the incidence of death in a specific population; 2) The loss of subjects during the course of the clinical research study
Classification System
1. A system for grouping similar diseases and procedures and organizing related information for easy retrieval. 2. A system for assigning numeric or alphanumeric code numbers to represent specific diseases and/or procedures.
Accreditation
1. A voluntary process of institutional or organizational review in which a quasi-independent body created for this purpose periodically evaluates the quality of the entity's work against preestablished written criteria 2. A determination by an accrediting body that an eligible organization, network, program, group, or individual complies with applicable standards
Standard
A model or example established by authority, custom, or general consent or a rule established by an authority as a measure of quantity, weight, extent, value, or quality.
Steps for ROI (generally)
1. Enter the request in the ROI database: information such as patient name, date of birth, health record number, name of requester, address of requester, telephone number of requester, purpose of the request, and specific health record information requested is entered in the computer. 2. Validity of the authorization is determined: The HIM professional will compare the authorization form signed by the patient with the facility's requirements for authorization to determine the validity of the authorization form. The facility's requirements are based on federal and state regulations. Certain types of information such as substance abuse treatment records, behavioral records, and HIV records require specific components be included in the authorization form per state (varies per state) and federal regulations. If the authorization is determined to be invalid, the request is returned to the requester with an explanation as to why the request has been returned. If valid to next step. 3. Verify the patient's identity: HIM professional must first verify that the patient has been a patient at the facility. Verification is done by comparing the information on the authorization with information in the master patient index (MPI). The patient's name, date of birth, social security number, address, and phone number are used to verify the identity of the patient whose record is requested. Patient's signature in the health record is compared with the patient's signature on the authorization for release of information form. 4. Process the request: the record is retrieved and the only information authorized for release is copied and released.
Prototype
A model or example of what a completed IS may look like. Allows for a maximum end-user input while speeding up the analysis and development process by simulating potential end versions of the system.
To examine results of experimental protocols
How do research organizations use the health record?
Nursing vocabularies
A classification system used to capture documentation on nursing care
Uniform Ambulatory Care Data Set (UACDS)
A data set developed by the National Committee on Viral and Health Statistics consisting of a minimum set of patient/client specific data elements to be collected in ambulatory care settings.
Data Dictionary
A descriptive list of the data elements to be collected in an information system or database whose purpose is to ensure consistency of terminology.
Natural language processing
A field of computer science and linguistics concerned with the interactions between computers and human (natural) languages that converts information from computer databases into readable human language
Operative report
A formal document that describes the events surrounding a surgical procedure or operation and identifies the principal participants in the surgery
Community Health Accreditation Program
A group that surveys and accredits both home healthcare and hospice organizations
Commission for the Accreditation of Birth Centers
A group that surveys and accredits freestanding birth centers
Hybrid record
A health record that includes both paper and electronic elements
Commission on Accreditation of Rehabilitation Facilities (CARF)
A private, not-for- profit organization that develops customer-focused standards for behavioral healthcare and medical rehabilitation programs and accredits such programs on the basis of its standards
National Committee for Quality Assurance (NCQA)
A private, not-for-profit accredi- tation organization whose mission is to evaluate and report on the quality of managed care organizations in the United States
Accreditation Association for Ambulatory Health Care (AAAHC)
A professional organization that offers accreditation programs for ambulatory and outpatient organiza- tions such as single- and multispecialty group practices, ambulatory surgery centers, col- lege/university health services, and community health centers
Medicare Conditions of Participation or Conditions for Coverage
A publication that describes the requirements that institutional providers (such as hospitals, skilled nursing facilities, and home health agencies) must meet to receive reimbursement for services pro- vided to Medicare beneficiaries
Nomenclature
A recognized system of terms used in science or art that follows pre-established naming conventions; a disease nomenclature is a listing of the proper name for each disease entity with its specific code number.
Medical history
A record of the information provided by a patient to his or her physician to explain the patient's chief complaint, present and past illnesses, and personal and family medical problems; includes a description of the physician's review of systems
True
A researcher uses data to determine the recommended treatment.
Data Stewardship
A responsibility, guided by principles and practices, to ensure the knowledgeable and appropriate use of data derived from individuals' personal health information.
Patient history questionnaire
A series of structured questions to be answered by patients to provide information to clinicians about their current health status
V codes
A set of ICD-9-CM codes used to classify occasions when circumstances other than disease or injury are recorded as the reason for the patient's encounter with healthcare providers.
Abbreviated Injury Scale (AIS)
A set of numbers used in a trauma registry to indicate the nature and severity of injuries by body system.
Healthcare Effectiveness Data and Information Set (HEDIS)
A set of standard performance measures designed to provide healthcare purchasers and consumers with the information they need to compare the performance of managed healthcare plans. Designed to collect administrative, claims, and health record review data. Includes data related to patient outcomes and data about treatment process used by the clinician in treating the patient. Sponsored by the National Committee for Quality Assurance (NCQA.
Programming Languages
A set of words and symbols that allows programmers to tell the computer what operations to follow.
Data Element
A single fact or measurement which represent facts. Ex: age, gender, insurance company, and blood pressure.
Core Data Elements
A small set of data elements with standardized definitions often considered to be the core of data collection efforts.
Outcomes and Assessment Information Set (OASIS)
A standard core assessment data tool developed to measure the outcomes of adult patients receiving home health ser- vices under the Medicare and Medicaid programs
Electronic Data Interchange (EDI)
A standard transmission format using strings of data for business information communicated among the computer systems of independent organizations.
Outcomes and Assessment Information Set (OASIS-C)
A standardized data set designed to gather and report data about Medicare beneficiaries who are receiving services from Medicare-certified home health agency.
Patient assessment instrument (PAI)
A standardized tool used to evaluate the patient's condition after admission to, and at discharge from, the healthcare facility
E codes ( external cause of injury code)
A supplementary ICD-9-CM classification used to identify the external causes of injuries, poisonings, and adverse effects of pharmaceuticals.
Source-oriented health record
A system of health record organization in which information is arranged according to the patient care department that provided the care
International Classification of Diseases for Oncology, Third Edition (ICD-O-3)
A system used for classifying incidences of malignant disease
Morbidity
A term refering to the state of being diseased (including illness, injury, or deviation from normal health); the number of sick persons or cases of disease in relationship to a specific population
Recovery room report
A type of health record documentation used by nurses to docu- ment the patient's reaction to anesthesia and condition after surgery; also called recovery room record
Pathology report
A type of health record or documentation that describes the results of a microscopic and macroscopic evaluation of a specimen removed or expelled during a surgical procedure
Palliative care
A type of medical care designed to relieve the patient's pain and suffering without attempting to cure the underlying disease
Population-based registries
A type of registry that includes information from more than one facility in a specific geopolitical area, such as a state or region.
Prospective Payment System
A type of reimbursement system that is based on preset payment levels rather than actual charges billed after the service has been provided.
Resident assessment instrument (RAI)
A uniform assessment instrument developed by the Centers for Medicare and Medicaid Services to standardize the collection of skilled nursing facility patient data; includes the Minimum Data Set 3.0, triggers, and resident assessment protocols
Which two major types of data are contained in the health record? A. Nursing and physician B. Administrative and clinical C. Demographic and financial D. Surgical and medical
Administrative and clinical
Which of the following is not considered patient demographic information? A. Patient's date of birth B. Name of next of kin C. Type of admission D. Admitting diagnosis
Admitting diagnosis
Which of the following is true about the Social Security Number?
Both AHIMA and the Social Security Administration oppose using the Social Security number as the health record identifier
Data analysis
According to the AHIMA data quality model, what is the term that is used to describe how data is translated into information?
AAAHC
Accreditation Association for Ambulatory Health Care
ACHC
Accreditation Commission for Health Care
Database Integrity
Accuracy, accessibility, comprehensiveness, consistency, currency, definition, granularity, precision, relevancy, and timeliness.
The goal of compliance programs is to prevent: A. Accusations of fraud and abuse B. Delays in claims processing C. Billing errors D. Inaccurate code assignments
Accusations of fraud and abuse
Data Standard
Agreed upon specifications for the values acceptable for specific data fields.
Medicare Part B covers: A. Services in an emergency department B. Ambulatory surgery center services C. Services in an outpatient clinic D. All of the above
All of the above
Medicare coverage applies to: A. Individuals age 65 and over B. Individuals who are disabled C. Individuals who undergo chronic kidney dialysis for end-stage renal disease D. All of the above
All of the above
To be eligible for federal matching funds, each state's Medicaid program must offer medical assistance for: A. Inpatient hospital services B. Prenatal care C. Vaccines for children D. All of the above
All of the above
The master patient index (MPI) is necessary to locate health records within the paper-based storage system for all the types of filing systems, except:
Alphabetical
Patient history questionnaires, problem lists, diagnostic tests results, and immunization records are commonly found in which type of record? A. Ambulatory care B. Emergency care C. Long-term care D. Rehabilitative care
Ambulatory care
AAAASF
American Association for Accreditation of Ambulatory Surgery Facilities
AOA
American Osteopathic Association
Which of the following was the original group of individuals eligible for Medicare? A. Americans over the age of 65 B. Patients with end-stage renal disease C. Those eligible for Railroad Retirement disability D. Those entitled to Social Security benefits
Americans over the age of 65
Healthcare Common Procedure Coding System (HCPCS)
An alphanumeric classification system that identifies healthcare procedures, equipment, and supplies for claim submission purposes; the three levels are as follows: 1) Current Procedural Terminology codes, developed by the AMA; 2) codes for equipment, supplies and services not covered by CPT codes as well as modifiers that can be used with all levels of codes, developed by CMS; 3) {eliminated 12/31/2003, to comply w/ HIPAA}, local codes developed by regional Medicare Part B carriers and used to report physicians' services and supplies to Medicare for reimbursement.
Authorization to disclose information
An authorization that allows the healthcare facility to verbally disclose or send health information to other organizations; See authorization
Computer-based patient record (CPR)
An electronic patient record housed in a system designed to provide users with access to complete and accurate data, practitioner alerts and reminders, clinical decision support systems, and links to medical knowledge; See electronic health record
Electronic medical record (EMR)
An electronic record of health-related information on an individual that can be created, gathered, managed, and consulted by authorized clini- cians and staff within a single healthcare organization
Electronic health record (EHR)
An electronic record of health-related information on an individual that conforms to nationally recognized interoperability standards and that can be created, managed, and consulted by authorized clinicians and staff across more than one healthcare organization
Operation Support Systems (OSS)
An information system that facilitates the operational management of a healthcare organization. Efficiently process business transactions, support communication and collaboration among business units, and update business databases. Example: R-ADT (Registration, Administration, Discharge, and Transfer.
Deemed status
An official designation indicating that a healthcare facility is in compli- ance with the Medicare Conditions of Participation; to qualify for deemed status, facilities must be accredited by the Joint Commission on Accreditation of Healthcare Organizations or the American Osteopathic Association.
American Association for Accreditation of Ambulatory Surgery Facilities (AAAASF)
An organization that sets standards for accrediting ambulatory surgical facilities
Indexes
An organized (usually alphabetical) list of specific data that serves to guide, indicate, or otherwise facilitate reference to the data.
Databases
An organized collection of data, text, references, or pictures in a standardized format, typically stored in a computer system for multiple applications.
Reviewing a health record for missing signatures and missing medical reports is called
Analysis
An inaccurately generated chargemaster affects reimbursement, resulting in A. Overpayments B. Underpayments C. Claims rejections D. Any of the above
Any of the above
Output devices
Any piece of computer hardware equipment used to communicate the results of data processing carried out by an information-processing system to the outside world. Most common example is the screen. Other examples are printers, faxes, and speakers.
Entity
Anything about which data can be stored and can be a concept, person, place, thing, or event.
EHRs are filed in paper folders
This statement does not pertain to electronic health records (EHR)s
E-Health
Application of e-commerce to the healthcare industry, including electronic data exchange and links among healthcare entities.
Public Health
Area of healthcare that deals with the health of populations in geopolitical areas, such as states and continues.
Operation Index
Arranged in numerical order by the patient's procedure code(s)
Which of the following chart-processing activities is eliminated with an EDMS that uses scanned images of barcoded forms? Chart preparation, Scanning, Assembly, Quality review
Assembly
Productivity Software
Assist with word processing, accounting, database management, graphics presentations, scheduling, e-mail, time management, and other functions performed in offices and homes.
Secondary data is used for multiple reasons including: A. Assisting researchers in determining effectiveness of treatments B. Assisting physicians and other healthcare providers in providing patient care C. Billing for services provided to the patient D. Coding diagnoses and procedures treated
Assisting researchers in determining effectiveness of treatments
Consider the following sequence of numbers: 12-34-55, 13-34-55, and 14-34-55. What filing system is being used if these numbers represent the health record numbers of three records filed together within the filing system.
B Terminal digit filing
What legislation mandated the implementation of a skilled nursing facility prospective payment system? A. BBA B. COBRA C. OBRA D. TEFRA
BBA
What department within the hospital uses the information abstracted and coded by the HIM department to send for payment from third-party payers?
Billing Department
Which of the following situations would be identified by the NCCI edits? A. Determine the MS-DRG B. Billing for two services that are prohibited from being billed on the same day C. Whether or not data that were submitted electronically were successfully submitted D. Receive the remittance advice
Billing for two services that are prohibited from being billed on the same day
What plans were the first prepaid health plans in the United States? A. Blue Cross and Blue Shield Plans B. Government-Sponsored Healthcare Programs C. Employer-Based Self-Insurance Plans D. Private Health Insurance Plans
Blue Cross and Blue Shield Plans
Which of the following is not true of good forms design for paper forms? a. Every form should have a unique identification number. b. Every form should have a clear, concise title. c. Bright colors should be used to identify forms. d. Paper ranging from twenty to twenty-four pounds in weight should be used for forms that will be copied, faxed, or scanned.
Bright colors should be used to identify forms.
Asymmetric Digital Subscriber Line (ADSL)
Cable modems connected through TV cable lines.
Which standardized tool is used to assess Medicare-certified rehabilitation facilities? A. Outcomes and Assessment Information Set (OASIS) B. Care area assessment (CAA) C. Patient assessment instrument (PAI) D. Minimum Data Set (MDS)
Care area assessment (CAA)
Which specialized type of progress note provides healthcare professionals impressions of patient problems with detailed treatment action steps? A. Flow record B. Vital signs record C. Care plan D. Surgical note
Care plan
After the types of cases to be included in a registry have been determined, what is the next step in data acquisition? A. Case registration B. Case definition C. Case abstracting D. Case finding
Case finding
Major medical insurance covers: A. Automobile accidents B. Ambulatory care C. Catastrophic illnesses D. Catastrophic illnesses and injuries
Catastrophic illnesses and injuries
Data Dictionary
Central building block that supports communication across business process. It improves data validity and reliability within, across, and outside the enterprise because it ensures that each piece of data can only mean one thing.
Which system records the location of health records removed from the filing system and documents the return of the health records? a. Chart deficiency system b. Chart tracking system c. Abstracting system d. None of the above
Chart tracking system
Edits
Check on the accuracy of data.
Which of the following is not usually a part of quantitative analysis review? a. Checking that all forms contain the patient's name and health record number b. Checking that all forms and reports are present c. Checking that every word in the record is spelled correctly d. Checking that reports requiring authentication have signatures
Checking that every word in the record is spelled correctly
Which of the following hospitals are excluded from the Medicare acute care prospective payment system? A. Children's B. Small community C. Tertiary D. Trauma
Children's
Medicare Provider Analysis and Review (MEDPAR) File
Collection of data from reimbursement claims submitted to the Medicare program by acute care hospitals and skilled nursing facilities (SNF) that is used to evaluate the quality and effectiveness of the care being provided.
Network
Collection of hardware components and computers interconnected by communication channels that allow sharing resources and information.
Disease Registries
Collections of secondary data related to patients with a specific diagnosis, condition, or procedure.
The Centers for Disease Control and Prevention (CDC)
Collects data from the NPCR state registries.
What feature of the filing folder helps locate misfiles within the paper-based filing system?
Color coding
Foreign Key
Column of one table that corresponds to a primary key in another table.
Dual work processes
refer to coexisting paper and electronic processes used in the hybrid health record evironment
Implementation Phase
Complex undertaking and includes the development of the computer programs, testing the system, and development of system documentation, user training, and system conversion.
What is compliance documentation?
Compliance documentation includes all records necessary to protect the integrity of the compliance process and confirm the effectiveness of the program, including employee training documentation, reports from hotlines, results of internal investigations, results of auditing and monitoring, modifications to the compliance program, and self-disclosures. The documentation should be retained according to applicable federal and state law and regulations and must be maintained for a sufficient length of time to ensure its availability to prove compliance with laws and regulations The organizations legal counsel should be consulted regarding the retention of compliance documentation.
Communications Technology Information Technology (IT)
Computer networks in an information system. Computer technology (hardware and software) combined with telecommunications technology (data, image, and voice networks); often used interchangeably with information system (IS)
Management Information System (MIS)
Computer-based system that provides information to a healthcare organization's managers for use in making decisions that effect a variety of day-to-day activities.
Clients
Computers that access shared resources.
Servers
Computers that share resources such as printers or hard-disk space across the network.
Aggregate Data
Considered secondary data. Data extracted from individual health records and combined to form deidentified information about groups of patients that can be compared and analyzed.
Data Warehouse
Consolidates and stores data from various databases throughout the enterprise. Designed to perform data analysis rather than support routine operations.
An attending physician requests the advice of a second physician who then reviews the health record and examines the patient. The second physician records impressions in what type of report? A. Consultation B. Progress note C. Operative report D. Discharge summary
Consultation
An advantage of HCUP is that it: A. Contains only Medicare data B. Is used to determine pay for performance C. Contains data on all payer types D. Contains bibliographic listings from medical journals
Contains data on all payer types
Master Population/Patient Index
Contains patient-identifiable data such as name, address, date of birth, dates of hospitalizations or encounters, name of attending physicians, and health record number.
American National Standards Institute (ANSI)
Coordinates the development of voluntary standards in a variety of industries, including healthcare.
Which of the following is a risk of copying and pasting?
Copying the note in the wrong patient's record.
National Survey of Ambulatory Surgery
Data collected on a representative sample of hospital-based and freestanding ambulatory surgery centers. Survey consists of a mailed survey about facility and abstracts of patient care.
Secondary Data Source
Data derived from the primary patient record, such as an index or a database.
National Home and Hospice Care Survey
Data is collected on the home health or hospice agency as well as on their current and discharged patients.
Vital Statistics
Data on birth, deaths, fetal deaths, marriages, and divorces.
Using uniform terminology is a way to improve: A. Validity B. Data timeliness C. Audit trails D. Data reliability
Data reliability
False data is raw facts and figures and information is data converted into a meaningful format.
Data and infromation mean the same thing
National Ambulatory Medical Care Survey
Data collected by a sample of office-based physicians and their staffs from the health records of patients seen in a one-week period.
Information
Data that has been collected, combined, analyzed, interpreted, and/or converted into a form that can be used for specific purposes. It represents meaning.
AHIMA's recommended destruction standards:
Destroy the records so there is no possibility of reconstruction of information. Paper - burning, shredding, pulping and pulverizing. Microfilm or microfiche- recycling and pulverizing. Laser disks- pulverizing electronic Data- magnetic degaussing leaving the domains in random patterns with no preference to orientation, rendering previous data unrecoverable. Total data destruction does not occur until the original data and all backup information have been destroyed. Magnetic tapes - degaussing
Which of the following is an accrediting organization? A. State regulating agencies B. American Health Information Management Association C. Det Norske Veritas Healthcare D. Centers for Medicare and Medicaid Services
Det Norske Veritas Healthcare
What type of algorithm(s) may be used to identify duplicate medical record numbers?
Deterministic, Probabilistic, and Rules Based.
A fee schedule is A. Developed by third-party payers and includes a list of healthcare services and procedures and charges of each B. Developed by providers and includes a list of healthcare services provided to a patient C. Developed by third-party payers and includes a list of healthcare services provided to a patient D. Developed by providers and lists charge codes
Developed by third-party payers and includes a list of healthcare services and procedures and charges of each
Receiver
Device that receives the information
John Smith, treated as a patient at a multi-hospital system, has three medical record numbers. The term used to describe multiple health record numbers is:
Duplicates
Which of the following is a disadvantage of an EHR over a paper-based record? A. Allows customization to user needs B. Permits multiple users at the same time C. Enables duplicate copies to be made easily D. Requires privacy and security measures
Enables duplicate copies to be made easily
Interdisciplinary care plans are an important part of which type of health record? A. Emergency department B. Ambulance C. End-stage renal disease D. Ambulatory care
End-stage renal disease
Primary Keys
Ensure that each row in a table is unique. Must not change in value. Number that is a one-up counter or a randomly generated number in large databases.
Uniform Definitions
Ensure that the data collected from a variety of healthcare settings will share a standard definition.
Enterprise Collaboration Systems
Example of an operations support system. They enhance teamwork and are sometimes called office automation systems. Examples: electronic mail, appointment scheduling, project management software to coordinate tasks and schedules, and voice conferencing.
Communication between caregivers
Examples of patient care delivery usage of the medical record include which of the following uses? A. Developing of pratice guidelines B. Communication between caregivers C. Reimbursement for patient care D. Getting patients involved in their own care
Written or spoken permission to proceed with care is classified as: A. Expressed consent B. Acknowledgment C. Advance directive D. Implied consent
Expressed consent
Food and Drug Administration (FDA)
Federal agency responsible for controlling the sale and use of pharmaceuticals, biological products, medical devices, food, cosmetics, and products that emit radiation, including the licensing of medications for human use.
Resident Assessment Instrument (RAI)
Federally mandated standard assessment used to collect demographic and clinical data on residents in a Medicare and/or Medicaid-certified long-term care facility.
These payment arrangements are streamlined by the use of chargemasters: A. Fee-for-service B. Per diem C. Prospective D. Retrospective
Fee-for-service
Prior to implementation of the MS-DRG prospective payment system, Medicare Part A payments to hospitals were based on a: A. Fee-for-service reimbursement methodology B. Level of care and expenditure for resources system C. Managed care capitated payment schedule D. Predetermined rate for each inpatient discharge
Fee-for-service reimbursement methodology
Machine Languages
First generation of programming languages, machine language, consists of ones and zeros.
determine whether standards of care are being met
How do accreditation organizations use the health record?
What is a Loose report?
HIM departments often receive reports belonging to a health record that has already been assembled or scanned. These unprocessed reports are called loose reports or loose filing.
Monitoring of Accreditation, licensure, and standards requiements
HIM director should establish a mechanism that targets specific regulatory or standards groups and monitors for compliance with these standards
Joint Commission Standards and elements of performance
HIM professional must consult the Comprehensive Accreditation Manual for Hospitals published by TJC for a complete listing of standards and elements of performance. The health records review process is a multidisciplinary process coordinated by the HIM dept.
Which of the following is a true statement about data stewardship? A. HIM professionals are not qualified to address data stewardship issues. B. Data stewardship addresses the needs of the healthcare organization but not the patient. C. HIM professionals have worked with many data stewardship issues for years. D. Data stewardship excludes privacy issues.
HIM professionals have worked with many data stewardship issues for years.
Evaluate the performance of individual patient care providers and to determine the effectiveness of the services provided.
How do patient care managers and support staff use the data documented in the health record?
Which of the following acts mandated establishment of the National Practitioner Data Bank? A. Health Care Quality Improvement Act of 1986 B. Health Insurance Portability and Accountability Act of 1996 C. Safe Medical Devices Act of 1990 D. Food and Drug Administration Modernization Act of 1997
Health Care Quality Improvement Act of 1986
Describe the electronic sharing of Information among two or more entities.
Health Information Exchange
HIE
Health Information Exchange= the sharing of health information electronically among two or more entities and also an organization that provides services to accomplish this information exchange.
Clinical Document Architecture (CDA)
Health Level 7 electronic exchange model for clinical documents (such as discharge summaries and progress notes).
One of the advantages of an EDMS is that it can:
Help manage work tasks
Portions of a treatment record may be maintained in a patient's home in which two types of settings? A. Hospice and behavioral health B. Home health and hospice C. Obstetric and gynecologic care D. Rehabilitation and correctional care
Home health and hospice
The ambulatory surgery record contains information most similar to: A. Physician's office records B. Emergency care records C. Hospital operative records D. Hospital obstetric records
Hospital operative records
Medicare Part A provides: A. Dental insurance B. Hospitalization insurance C. Outpatient insurance D. All of the above
Hospitalization insurance
Which of the following is a reason why the high percentage of uninsured is a concern? A. With so many uninsured insurance companies may not make a profit. B. Hospitals cannot afford to provide care to uninsured patients. C. Generally speaking, uninsured patients receive medical care at the first sign of a problem. D. There are not enough insurance companies available to insure all of the uninsured if they decide to purchase insurance.
Hospitals cannot afford to provide care to uninsured patients.
Physical Topology
How data flows through a network.
The term used to describe a combination of paper-based and electronic health records is:
Hybrid
Which type of health record includes both paper and electronic components? A. Hybrid B. Electronic C. Problem-oriented D. Source-oriented
Hybrid
What is record reconciliation?
Hybrid System, upon patient discharge, receipt of the health record is checked with a discharge list for completeness.
All of the above
Inaccurate data recorded in the health record could: A. Compromise quality patient care B. Contribute to incorrect assumptions by policy makers C. Invalidate research findings D All of the above
This model of HMO is created when physicians join together in an organized group for the purposes of fulfilling a contract but retain individual practices: A. Group B. Independent practice association C. Network model D. Staff
Independent practice association
Certified Tumor Registry (CTR)
Individual who has achieved specialized skills in the cancer registry.
Future directions in Health Information Management Technology:
Influencing factors: - Political initiatives - Expansion of Network capabilities - Emergence ofnew technologies such as EHRs, natural language processing, and computer-assisted coding -Move toward ICD-10-CM and ICD-10-PCS - Societal and regulatory requirements for information privacy and security - Greater demand and accountability for improved healthcare quality and patient safety that can be facilitated through the use of information technology - Increased consumer knowledge of personal healthcare decisions and increased focus on personal health records
Knowledge Management System (KMS)
Information system that has the potential to increase work effectiveness. Supports the creation, organization, and dissemination of business or clinical knowledge and expertise to providers, employees, and managers throughout the healthcare enterprise.
Management Support Information Systems
Information systems that provide information primarily to support manager decision making.
Information System Activities
Input, Processing, Output, Storage, and Controlling.
Strategies for MPI Integrity
Integrity must be maintained in order to avoid patient safety, customer service, risk management, legal and other issues. MPI cleanup process - uses matching algorithms to identify and fix these problems. 3 types: are often part of the MPI application: a DETERMINISTIC algorithm requires an exact match of combined data elements such as name, birth date, sex, and social security number. PROBABILISTIC algorithm is base on complex mathematical formulas that analyze facility specific MPI data to determine precisely matched weight probabilities for attribute values of various data elements. RULES-BASED algorithm assigns weights, for significant values, to particular data elements and later uses these weights in the comparison of one record to another.
Simple Mail Transfer Protocol (SMTP)
Internet standard for electronic mail transmission across Internet Protocol (IP) networks.
Which of the following is not true about document imaging? a. It allows random access for retrieval of documents. b. It can be viewed by more than one person at a time. c. It can be viewed from locations remote from the HIM department. d. It is a paperless system.
It can be viewed from locations remote from the HIM department.
Consistency
It was suggested that we enter the patient's age manually in all of our information systems rather than having it entered once in one system and interfaced to the other systems. What quality characteristic would be the justification for not doing this manual entry into each information system
Claims
Itemized statement of healthcare services and their costs provided by a hospital, physician's office, or other healthcare provider; submitted for reimbursement to the healthcare insurance plan by either the insured party or by the provider.
Which of the following is not true of good forms design for electronic forms? a. Keystrokes should be minimized by using pop-up menus. b. Electronic forms should use completeness checks. c. Electronic forms should use radio buttons for multiple selections of items. d. Electronic forms should use text boxes to enter text.
Keystrokes should be minimized by using pop-up menus.
Enterprise-wide System Enterprise Resource Planning System (ERP)
Large information system that manages data for an entire healthcare business.
Hypertext Transfer Protocol (HTTP)
Protocol used to transfer and display information in the form of web pages on browsers.
Accession Registry
List of cases in a cancer registry in the order in which they were entered.
Physician Index
Listing of cases in order by physician name or physician identification number. Enables users to retrieve information about a particular physician.
Paper records may require thinning in which two settings? A. Home health and hospice B. Rehabilitation and end-stage renal disease C. Ambulatory care and behavioral health D. Long-term care and correctional services
Long-term care and correctional services
Agency for Healthcare Research and Quality (AHRQ)
Looks at issues related to the efficiency and effectiveness of the healthcare delivery system, disease protocols, and guidelines for improved disease outcomes.
Which of the following is the tool used to collect resident assessment data so that the SNF residents can be assigned to the appropriate resource utilization group? A. MDS B. RAP C. RAVEN D. RUG
MDS
Destruction services for destruction of records
MUST meet HIPPA Privacy Rule and in addition: Indemnify the healthcare facility from loss due to unauthorized disclosure Require that the business associate maintain liability insurance in specified amounts, at all times the contract is in effect. Provide proof of destruction Specify the method of destruction Specify the time that will elapse between acquisition and destruction of data The method of destruction should be reassessed annually, based on current technology, accepted practices, and availability of timely and cost-effective destruction services.
Trauma Registries
Maintain databases on patients with severe traumatic injuries.
MS-diagnostic-related groups are organized into: A. Case-mix classifications B. Geographic practice cost indices C. Major diagnostic categories D. Resource-based relative values
Major diagnostic categories
This nonprofit organization contracts with physicians to manage their practices and owns clinical/business resources that are made available to participating physicians: A. Exclusive provider organization B. Group practice without walls C. Management service organization D. Medical foundation
Management service organization
Which of the following indexes is an important source of patient health record numbers? A. Physician index B. Master patient index C. Operation index D. Disease index
Master patient index
Implant
Material or substance inserted into the body, such as breast implants, heart valves, and pacemakers.
Analytic Models
Mathematical interpretations of real systems such as pharmacy drug inventory systems.
Medium
Mechanism that connects the transmitter to the receiver or the air.
The function within the HIM department responsible for listening to dictated reports and typing them into a medical report format is called:
Medical transcription
Processor
Microchip implanted in a CPU's hardware that processes instructions sent to it by the computer and software programs.
Exception Report
Might be a monthly report that lists the percentage of incomplete records.
Demographic Information
Name, health record number, and address.
NCQA
National Committee for Quality Assurance
Which group focuses on accreditation of managed care? A. Accreditation Association for Ambulatory Healthcare B. National Committee for Quality Assurance C. Commission on Accreditation of Rehabilitation Facilities D. The Joint Commission
National Committee for Quality Assurance
National Vaccine Advisory Committee (NVAC)
National advisory group that supports the director of the National Vaccine Program.
The North American Association of Central Cancer Registries (NAACCR)
National organization that certifies state, population-based cancer registries.
Sleeping patterns, head and chest measurements, feeding and elimination status, weight, and Apgar scores are recorded in which of the following records? A. Obstetric B. Newborn C. Surgical D. Emergency
Newborn
Under the False Claims Act, claims may be brought up to how many years?
No more than 7 years
measures limit an EHR's user's ability to deny (repudiate) the origination receipt or authorization of a data exchange by that user
Nonrepudiation - means to accept ie. electronic signatures
In a problem-oriented health record, problems are organized by: A. Letter B. Number C. Patient name D. Body system
Number
Accession Number
Number assigned to each a case as it is entered in a cancer registry. The first digits are the year the patient was first seen at the facility.
What are the benefits of document imaging?
One of the greatest benefits of document imaging is increased efficiency by eliminating the requirement to move and track paper documents through workflow. Also helps solve the problem of lost or misplaced paper or microfiche documents. It saves money by reducing the need for storage space and by decreasing the work of file clerks.
Mainframes
Only computers available until the 1960s. They can perform millions of instructions per second, are designed to connect input/output devices over a long distances, and can handle hundreds or thousands of users at the same time. Used in hospitals to store payroll, personnel, billing, and accounting data.
Association of Record LIbrarians of North America (ARLNA)
Organization formed 10 years after the beginning of the hospital standardization movement whose original objective was to elevate the standards of clincial recordkeeping in hospitals, dispensaries, and other healthcare facilities; preucrosr of the Americna Health Information Management Association
Database
Organized collection of data saved as a binary-type file on a computer.
Digital Imaging Communication in Medicine (DICOM)
Originally created to permit the interchange of biomedical image wave forms and related information.
Source oriented health record
Our record has all of the lab filed together, all of the progress notes filed together, and so on. What format are we using?
OASIS
Outcomes and Assessment Information Set
Output
Outcomes of inputs into a system.
The tool used to track paper-based health records is
Outguide
What is the most common type of tracking system used to track paper-based health records?
Outguide - usually made of strong colored vinyl with two plastic pockets. It is the size of a regular record folder and is placed in the record location when the record is removed from the file.
Injury Severity Score (ISS)
Overall severity measurement maintained in the trauma registry and calculated from the abbreviated injury scores for the three most severe injuries of each patient.
What is used to determine compliance with the Joint Commission standards?
PPR - periodic performance review PFP - Priority focus process that facilitates the newer continual standards, compliance process
Health Information Technology Expert Panel
Panel charged to create a better link between current quality measurement and EHR reporting capabilities.
Which of the following reports provides information on tissue removed during a procedure? A. Operative report B. Laboratory report C. Pathology report D. Anesthesia report
Pathology report
Paper based identification systems patient ID: Serial numbering System
Patient receives a unique numerical identifier for each encounter or admission to a healthcare facility. Disadvantage: information about the patient's care and treatment is filed in separate health records and at separate locations. retrieval more difficult. inefficient.
Problem-oriented health record
Patient record in which clinical problems are defined and documented individually
The health record number is typically assigned by:
Patient registration
Where doe the health record begin?
Patient registration
The computer system that may serve as the MPI function is the:
Patient registration system
Bob Smith is a 56-year-old white male. This is an example of what type of data? A. Patient-specific B. Primary C. Aggregate D. Secondary
Patient-specific
False
Patients do not have the right to add missing information to the health record?
Self-extubation
Patients removing their own tubes
The inpatient psychiatric facility prospective reimbursement system is based on: A. MS-DRGS B. Per diem rate C. RUGS-IV D. CMGs
Per diem rate
Patient-specific/identified data Patient identifiable data
Personal information that can be linked to a specific patient, such as age, gender, data of birth, and address.
This arrangement makes it possible for the managed care market to view hospitals and physicians as a single entity for the purpose of contracting services: A. Management service organization B. Medical foundation C. Physician-hospital organization D. Point-of-service plan
Physician-hospital organization
The MS-DRG prospected payment system rate is based on what type of diagnosis? A. Primary B. Principal C. Admitting D. Additional
Principal
These types of plans allow beneficiaries to go to any doctor or hospital that accepts the terms of the plan's payment: A. Managed care plans B. PPO plans C. Private fee-for-service plans D. Medicare specialty plans
Private fee-for-service plans
Standards Development Organizations (SDOs)
Private or government agencies involved in the development of healthcare informatics standards at a national or international level.
The document that indicates current and past medical conditions is: A. MDS B. CAAs C. Problem list D. PAI
Problem list
Credentialing
Process of reviewing and validating the qualifications (degrees, licenses, and other credentials) of physicians and other licensed independent practitioners, for granting medical staff membership to provide patient care services.
Abstracting
Process of reviewing the patient health record and entering the required data elements into the database.
File Transfer Protocol (FTP)
Protocol used to exchange and manipulate files over a TCP/IP network.
Design Phase
Specifies the functions of the system and provides the design or blueprint of the proposed system.
Fellowship Program
Program of earned recognition for AHIMA members who have made significant and sustained contributions to the HIM profession through meritorious service, excellence in professional practice, education,and advancement of the profession through innovation and knowledge sharing
The type of payment system where the amount of payment is determined before the service is delivered is called: A. Fee-for-service B. Per diem C. Prospective D. Retrospective
Prospective
Security
Protection of healthcare information from damage, loss, and unauthorized alteration is also known as
I started work today on a clinical trial. I need to familiarize myself with the rules and procedures to be followed. This information is called the: A. Protocol B. MEDPAR C. UMLS D. HCUP
Protocol
Connection Release Phase
Protocol allows the computers to terminate the connection.
Data Transfer Phase
Protocol that allows the computers to transfer data.
Integrity Constraints
Provide a way of ensuring that data that are entered or updated in a database by authorized users do not result in a loss of data quality.
Data Models
Provide contextual framework and graphical representation that aid in the definition of data elements.
To accept assignment means that the A. Patient authorizes payment to be made directly to the provider B. Provider accepts as payment in full whatever the payer reimburses C. Balance billing is allowed on patient accounts, but at a limited rate D. Participating provider always receives a higher rate of reimbursement
Provider accepts as payment in full whatever the payer reimburses
Unified Medical Language System (UMLS)
Provides a way to integrate biomedical concepts from a variety of sources to show their relationships.
National Nursing Home Survey
Provides data on each facility, current residents, and discharged residents. Information is gathered through an interview process.
Institute of Electrical and Electronics Engineers (IEEE)
Provides for open-systems communications in healthcare applications, primarily between bedside medical devices and patient care information systems, optimized for the acute care setting.
HITECH component to ARRA
Provides funding to community colleges to train individuals in the following roles: -Practice workflow and information management redesign specialists -Clinician/practitioner consultants -Implementation support specialists - Implementation managers -Technical/software support staff -Trainers
Decision Support System (DSS)
Provides information to help users make accurate decisions. Analytic models included.
The forms design committee:
Provides oversight for the development, review, and control of forms and computer screens
HIT Standards Committee (HITSC)
Provides recommendations to the National Coordinator on standards, implementations specifications, and certification criteria for the electronic exchange and use of health information for purposes of adoption, consistent with the implementation of the Federal Health IT Strategic Plan, and in accordance with policies developed by the HIT Policy Committee.
Which of the following is the appropriate method for destroying microfilm?
Pulverizing
Removing health records from the storage area to allow space for more current records is called:
Purging records
Uniform Hospital Discharge Data Set (UHDDS)
Purpose is to list and define a set of common, uniform data elements.
Immunization Registries
Purpose of increasing the number of infants and children who receive the required immunizations at the proper intervals.
Maintenance - To ensure the integrity of the MPI, several quality control mechanisms are essential and include:
Quality - MPI prone to errors: misspellings, incorrect demographic data, transposition of numbers, and typographical errors are a few. Can cause treatment errors, billing problems and distorting data analysis of the organization's patient population. Duplicate, Overlay, and Overlap Medical Record Number Issues - Patient info not found upon admission and new record created; Or patient matched with wrong health record
Purposes for collecting secondary data
Quality, performance, patient safety. Research. Population Health. Administration.
Critical support services managed by HIM
Record processing, Monitoring of record completion, transcription, release of patient information, clinical coding, abstracting, and clinical data analysis
The hospital needs to know how much Medicare paid on a claim so they can bill the secondary insurance. What should they refer to? A. Explanation of Benefits B. Medicare Summary Notice C. Remittance advice D. Coordination of benefits
Remittance advice
RAI
Resident assessment instrument
Server-Based Database Management System
Runs on a server; runs as a separate application from a personal computer system.
Which program provides additional federal funds to states so that Medicaid eligibility can be expanded to include a greater number of children? A. Medicaid B. Medigap C. SCHIP D. PACE
SCHIP
Which of the following is an example of how the HIM professional interacts with the medical staff
Serves on medical staff committee
Row/Record
Set of columns or a collection of related data items.
Business Process
Set of related policies and procedures that are performed step by step to accomplish a business-related function.
Relevancy
Someone suggested that we collect a patient's eye color. This was not implemented. What quality characteristic would be the justification for not collecting this information?
Stakeholder
Someone who is affected by an issue.
Intranet
Specialized client/server network that uses Internet technologies.
Encoder
Specialty software used to facilitate the assignment of diagnostic and procedural codes according to the rules of the coding system
Encoder
Specialty software used to facilitate the assignment of diagnostic and procedural codes according to the rules of the coding system.
This model of HMO employs physicians and other healthcare professionals to provide healthcare services to members: A. Group B. Independent practice association C. Network D. Staff
Staff
How do they ensure the integrity of patient identity in health information exchange
Standardization of health information exchange practices is paramount.
Core measures
Standardized performance developed to improve the safety and quality of healthcare. Based on selected diagnosis/conditions.
Statements that define the performance expectations and/or structures or processes that must be in place are:
Standards
Conditions for Coverage
Standards applied to facilities that choose to participate in fed- eral government reimbursement programs such as Medicare and Medicaid; See Condi- tions of Participation
Interoperability
Standards needed in order for data to be easily, accurately, and securely communicated and exchanged electronically among various computer systems.
Transaction Standards
Standards that support the uniform format and sequence of data during transmission from one healthcare entity to another.
Record retention should be based on:
State regulations and AHIMA recommendations
Relational Database
Stores data in predefined tables that contain rows and columns similar to a spreadsheet. Data that can be stored is currency, real numbers, integers, and strings (characters of data).
How are amendments handled in the EHR?
The amendment must have a separate signature, date and time.
The patient indicates that her pain is worse. In which part of a SOAP note would this information be recorded? A. Subjective B. Objective C. Assessment D. Plan
Subjective
SOAP
Subjective, objective, assessment, plan
False
Submitting health record documentation to a third-party payer for the purpose of substantiating a patient bill is considered a secondary purpose of the health record.
Data Elements for Emergency Department Systems (DEEDS)
Support the uniform collection of data in hospital-based emergency departments and to reduce incompatibilities in emergency department records.
A healthcare program for active duty members of the military and other qualified family members is called: A. HIS B. Medicare C. Medicaid D. TRICARE
TRICARE
Services
Tasks that a network server performs, such as facilitating e-mail, web, Internet, and printer connections; providing database access; performing backups; providing network communication; coordinating security; and managing files.
Accessibility, Consistency, Currency, Granularity, Precision, Accuracy, Comprehensiveness, Definition, Relevancy, Timeliness
The 10 characteristics of data quality
Diagnostic and Statistical Manual of Mental Disorders, Fourth Revision, Text Revision (DSM-IV-TR)
The 2004 text revision of the DSM-IV with updated clinical terms, but very few coding changes
American Academy of Professional Coders
The American Academy of Professional Coders provides certified credentials to medical coders in physician offices, hospital out-patient facilities, ambulatory surgical cetners, and in payer organizations
Access Control for EHRs
The center of Medicare and Medicaid Services EHR certification criteria requires access control of the EHR. It states: "Assign a unique name and/or number for identifying and tracking user identity and establish controls that permit only authorized users to access electronic health information"
Retention of EHR
The facility must consider state and federal regulations, statutes of limitation, research and educational needs, and patient care needs. There must also be a policy for the destruction of computer equipment and computer storage media when it is no longer functioning or has become obsolete.
National Center for Health Statistics (NCHS)
The federal agency responsible for collecting and disseminating information on health services utilization and the health status of the population in the United States.
Read codes
The former name of the United Kingdom's CTV3 codes; named for James Read, the physician who originally devised the system to organize computer-based patient data in his primary care practice
Centers for Medicare and Medicaid Services (CMS)
The division of the Department of Health and Human Services that is responsible for developing healthcare policy in the United States and for administering the Medicare program and the federal portion of the Medicaid program; called the Health Care Financing Administration (HCFA) prior to 2001
Progress notes
The documentation of a patient's care, treatment, and therapeutic response that is entered into the health record by each of the clinical professionals involved in a patient's care, including nurses, physicians, therapists, and social workers
A Hybrid record
The hospital where I work is transitioning to an EHR. In the meantime, we have part of the health record electronic and part is still paper. This concept is known as
Minimum Data Set (MDS) for Long-Term Care
The instrument specified by the Cen- ters for Medicare and Medicaid Services that requires nursing facilities (both Medicare certified and/or Medicaid certified) to conduct a comprehensive, accurate, standardized, reproducible assessment of each resident's functional capacity
National Commission on Correctional Health Care
The instrument specified by the Cen- ters for Medicare and Medicaid Services that requires nursing facilities (both Medicare certified and/or Medicaid certified) to conduct a comprehensive, accurate, standardized, reproducible assessment of each resident's functional capacity
Licensure
The legal authority or formal permission from authorities to carry on certain activities that by law or regulation require such permission (applicable to institutions as well as individuals)
Hardware
The machines and media used in an information system.
What dictates how the specific functions are carried out?
The medium in which the information is stored.
Integrated health record
The paper-based health record format that organizes all forms in chronological order is known as the
Data analysis
The processes by which data are translated into information that can be used for designated application
American Osteopathic Association (AOA)
The professional association of osteopathic physicians, surgeons, and graduates of approved colleges of osteopathic medicine that inspects and accredits osteopathic colleges and hospitals
American Health Information Management Association
The professional membership organization for managers of health record services and healthcare information systems as well as coding services; provides accreditation, certificaiton, and educational services
Care plan
The specific goals in the treatment of an individual patient, amended as the patient's condition requires, and the assessment of the outcomes of care; serves as the pri- mary source for ongoing documentation of the resident's care, condition, and needs
Expressed consent
The spoken or written permission granted by a patient to a healthcare provider that allows the provider to perform medical or surgical services
Implied consent
The type of permission that is inferred when a patient voluntarily sub- mits to treatment
Community College Consortia to Educate Health Information Technology Professionals
This is divided the country into five regional groups of 82 colleges that receive funding throught the Office of the National Coordinator for Health IT to create nondegree ac academic programs, which can be completed by infomration technology or healthcare professionals in six months or less.
What is the determining factor in whether a document is considered part of the legal health record.
This is not determined by where the information resides or its format, but rather how the information is used and whether it is reasonable to expect the information to be routinely released when a request for a complete health record is received.
How are materials from other facilities documented in the EHR?
They are scanned and filed in the EHR.
Which of the following is true of paper-based records? A. They are susceptible to damage from fire or floods. B. They lack standardization. C. They are easy to access and update. D. They require a limited number of personnel to process.
They are susceptible to damage from fire or floods.
Implant Registries
Tracks the performance of implants, including complications, deaths, and defects resulting from implants, as well as implant longevity.
Third-party payers and/or patients issue payments to healthcare providers after healthcare services have been provided and payments are based on the specific services delivered refers to ____________ reimbursement? A. Managed Fee-for-Service B. Traditional Fee-for-Service C. Episode-of-Care D. Fee-for-Service
Traditional Fee-for-Service
System Development Life Cycle (SDLC)
Traditional way to plan and implement an IS in an organization. Major phases of the cycle are planning, analysis, design, implementation, and maintenance.
business-to-business (B2B)
Transaction(s) between business. For example, between a wholesaler and a retailer.
business-to-customer (B2C)
Transactions between business and public consumers.
What type of registry maintains a database on patients injured by an external physical force? A. Implant registry B. Birth defects registry C. Trauma registry D. Transplant registry
Trauma registry
True or False: A corporate compliance program should include the development and implementation of education and training programs for all affected employees.
True
True or False: A registry is a secondary data source
True
True or False: Administrative and management staff members are internal users of secondary data.
True
True or False: Among the HIM professional's traditional roles is that of maintaining the confidentiality of health data.
True
True or False: An interface is the total component of screens, navigation, and input mechanisms used to operate encoding software.
True
True or False: Good encoding software should include edit checks
True
True or False: Good encoding software should include edit checks to ensure data quality.
True
True or False: In the future, coders' roles will change.
True
True or False: Medicare Administrative Contractors serve as the financial agent between providers and the federal government to locally administer Medicare Part A and Part B.
True
True or False: One advantage to a vendor system is that purchasers can find out about the system's performance from other users.
True
True or False: The 837P is submitted to Medicare carriers to process hospital outpatient claims.
True
True or False: The NLP encoding system uses expert or artificial intelligence software to automatically assign code numbers.
True
True or False: The OCE applies a set of logical rules.
True
True or False: EHR data are captured by scanning and direct entry.
True
True or False: Policies should address how the patient information will be removed from computers at the end of their useful life.
True
True or false Addendums should document the date the event actually happened - not the date it was documented
True
True or false The best practices for forms design is to use white paper with black ink
True
In which system are all encounters or patient visits kept in one folder?
Unit numbering system
The system in which a health record number is assigned at the first encounter and then used for all subsequent healthcare encounters is the:
Unit numbering system
The practice of assigning a diagnosis or procedure code specifically for the purpose of obtaining a higher level of payment is called: A. Billing B. Unbundling C. Upcoding D. Unnecessary service
Upcoding
Primary purpose of the health record
Use of the health record by a clinician to facilitate quality patient care is considered
Secondary purpose of the health record
Use of the health record to monitor bioterrorism activity is considered
False
Use of the health record to study the effectiveness of a given drug is considered a primary use of the health record.
High-level Languages
Use words and arithmetic phases to construct programs such as COBOL and BASIC
Aggregate Data
Used to develop information about groups of patients. Information may be used to identify common characteristics that may predict the course of the disease or provide information about the most effective way to treat it.
Medical Literature, Analysis, and Retrieval System Online (MEDLINE)
Used to locate articles on HIM issues as well as articles on medical topics necessary to carry out quality improvement and medical research activities.
Structured Query Language (SQL)
Used to store and retrieve data in relational databases. It gives information system the ability to query and report on data and to insert, update, and delete data from the database.
Healthcare Cost and Utilization Project (HCUP)
Uses data collected at the state level from either claims data or discharge abstract data, including the UHDDS items reported by individual hospitals, and in some cases, by freestanding ambulatory care centers.
Analysis Phase
Usually initiated by the submission of a project requisition or request from a department for the development, modification or purchase of an information system.
Computer-assisted coding
Utilizes natural language processing (NLP) and algorithmic software to electronically analyze entire medical charts to pre-code with both CPT procedure and ICD-9 diagnostic nomenclature
Joint Application Development (JAD)
Valuable technique used to identify the goals, objectives, and required functions of a proposed information system. Made up of a group of end users, system analysts, and technical development professionals who are brought together to analyze the strengths and weaknesses of the current IS and to propose functionalities for the new system.
Workstation
Very powerful desktop computer used mainly by power users such as graphics specialists for multimedia production.
Which of the following would not be found in a medical history? A. Chief complaint B. Vital signs C. Present illness D. Review of systems
Vital signs
Telecommunications
Voice and data communications within an organization.
What is another method used to capture dictated reports in the EHR
Voice recognition technology - computer software captures the dictation and converts the dictation to text. Back end voice recognition software or voice recognition at the point of transcription is most commonly used for routine transcription of reports. As the practice of medical transcription evolves and voice recognition software is utilized, emphasis is placed on medical language editing, data quality control, and text/document management.
Data comprehensiveness
When all required data elements are included in the health record, the quality characteristic for ________________ is met.
bundled payments
a category of payments made as lump sums to providers for all healthcare services delivered to a patient for a specific illness and/or over a specified time periodl. they include multiple services and may include multiple providers of care.
What is overlap?
When more than one medical record number exists for the same patient within an enterprise at different facilities or in different databases. Often occur in organization with multiple facilities or can occur in the health information exchanges. Frequently problem arises when there are facility or organization mergers and an enterprise master person/patient index (EMPI) is created
Patient Care Management
Which of the following is an example of a primary purpose of the medical record? A. Education B. Policy making C. Research D. Patient Care management
Data granularity
a characteristic of data whose values are defined at the appropriate level of detail, the level of detail at which the attributes and values of healthcare data are described
hybrid health record
a combination of paper and electronic records; a health record that includes both paper and electronic elements
Third party-payer
Which of the following users of the health record is an exmple of an institutional user? A. Third party-payer B. Patient C. Physician D. Employer
Patient care managers and support staff
Which of the following users would utilize aggregate data? A. Patient care providers B. Coding and billing staff C. Law enforcement officers D. Patient care managers and support staff
allied health professional
a credentialed healthcare worker who is not a physician, nurse, psychologist, or pharmacist
BC/BS federal employee program (FEP)
a federal program that offers a fee for service plan with preferred provider organizations and a point of service product
Traumatic Injury
Wound or other injury caused by an external physical force such as an automobile accident, a shooting, a stabbing, or a fall. May be used for performance improvement and research.
Autopsy report
Written documentation of the findings from a postmortem pathological examination
all patient DRGs (AP-DRGs)
a case mix system developed by 3M and used in a number of state reimbursement systems to classify non-Medicare discharges for reimbursement purposes
all patient refined DRGs (APR-DRGs)
a case mix system develped by 3M and sued in a number of state reimbursement systesm to classify non-Medicare discharges for reimbursement purposes
Clinical Vocabulary
a formally recognized list of preferred medical terms
confidentiality
a legal and ethical concept that establishes the healthcare provider's responsibility for protecting heatlh records and other personal and private information from unauthorized use or disclosure
data quality management
a managerial process that ensures the integrity (acuracy and completeness) of an organization's data during data collection, application, warehousing, and analysis
complication
a medical condition that arises during an inpatient hospitalization
comorbidity
a medical condition that coexists with the priamry cause for hospitalization an daffects the patient's treatment and length of stay
health record
a paper or computer based tool for collecting and storing information about the healthcare services provided to a patient in a single healthcare facility; also called a patient reocrd, medical record, resident record, or client record depending on the healthcare setting
Curriculum
a prescribed course of study in an educational program
accreditation organization
a professional organiztion that establishes the standards against which healthcare organizations are measured and conducts periodic assessments of the performance of individual healthcare organizations
security
a program designed to protect patient privacy and to prevent unauthorized access, alteration, or destruction of health records
balance billing
a reinbursment method that allows providers to bill patients for charges in exces of the amount paid by the patients' health plan or other third party payer
transcriptionist
a specially trained typist who understands medical terminology, and translates physicians' verbal dictation into written reports
Code of Ethics
a statement of ethical principles regarding business practices and professional behavior
Advance Beneficiary Notice of Noncoverage (ABN)
a statement signed by the patient when he or she is notified by the provider, prior to a service or procedure being done, that Medicare may not reimbure the provider for the service, wherein the patient indicates that he will be responsible for any charges
integrated health record format
a system of health record organization in which all the paper forms are arranged in strict chronological order and mixed with forms created by different departments
source-oriented health record
a system of health record organization in which informaiton is arranged according to the patient care department that provided the care.
accept assignment
a term used to refer to a provider's or a supplier's acceptance of the allowed charges (from a fee schedule) as payment in full for services or materials provided
Registered Health Information Administrator (RHIA)
a type of certification granted after completion of an AHIMA-accredited four-year program in health information management and a credentialing examination
Registered Health Information Technician (RHIT)
a type of certification granted after completion of an AHIMA-accredited two year program in health information management and a credentialing exam
accreditation
a voluntary process of institutional or organizational review in which a quasi-independent body created for this purpose periodically evaluates the quality fo the entity's work agianst preestablished written criteria. 2. a determination by an accrediting body that an eligible organization, network, program, group, or individual complies with applicable standards
coding professional responsibilities include
abstracting data and assigning codes using ICD-9-CM and CPT for a hospital stay and for translating healthcare providers' diagnostic and procedural documentation into coded form using code sets such as ICD-9-CM, CPT, HCPCS Level II. May be done manually or by using an Encoder. MS-DRG and APC groupers for acute care hospitals.
addendum
additional health information within the health record: Document the current date and time Write addendum and state the reason for the addendum, referring back to the original entry. Identify any sources of information used to support the addendum When writing an addendum, complete it as soon after the original note as possible.
cost outlier adjustment
additional reimbursement for certain high cost home care cases boased on teh loss sharing ratio of costs in excess of a threshold amount for each homoe health resource group
Major functions of revenue cycle management
admitting/access management, case management, charge capture, HIM, patient financial services/ business office, finance, compliance, and information technology.
personal health record (PHR)
an electronic record of health related information on an individual that conforms to nationally recognized interoperability standards and that can be drawn form multiple sources while being managed and controlled by the individual
National Cancer Registrars Association (NCRA)
an organization of cancer registry professionals that promotes research and education in cancer registry administration and practice
quality improvement organziation (QIO)
an organization that performs medical peer review of Medicare and Medicaid claims, including review of validity of hospital diagnosis and procedure coding information; completeness, adequacy, and quality of care; and appropriateness of prospective payments for outlier cases and nonemergent use of the emergency room; until 2002 called peer review organization
utilization management organization
an organization that reviews the appropriateness of the care setting and resources used to treat a patient.
reimbursement
compensation or repayment for healthcare services
Computer Assisted coding (CAC)
computer software used to generate ICD-9-CM or ICD-10-CM/PCS and CPT codes for each episode of care.
data timeliness
concept of data quality that invovles whether the data is up to date and available within a useful time frame, is determined by how the data are being used and their context
coinsurance
cost sharing in which the policy or certificate holder pays a preestablished percentage of eligible expenses after the deductible has been met
aggregate data
data extracted from individual health records and combined to form de-identifited information about groups of patients that can be compared and analyzed
When a hospital accredited by Joint Commission is considered to be in compliance with Medicare's Conditions of Participation, this is called:
deemed status
Incomplete records that are not completed by the physician within the time frame specified in the healthcare facility's policies are called:
delinquent records
operation index
diagnoses and operative codes, like those used in a classification system such as ICD-9-CM are used as guides or pointers to the health records of patients who have had a specific disease or operation. They are essential for locating health records to conduct quality improvement and research studies, as well as monitoring quality of care
Paper based corrections
draw a single line through the original entry, writing error above the entry and then the practitioner signs, dates, and times the correction.
ad hoc reporting capabilities
enable the user to select the field items he or she wants in the reports
ambulatory payment classification (APC) system
hospital outpatient prospective payment system (HOPPS) syste. within a group, the diagnoses and procedures are similar in tersm of resources used, complexity of illness and conditions represented. a singel payment is made for the outpatient services provided.
combination of paper-based and electronically stored healthcare records
hybrid record - it is a transitional health record that at some point becomes an electronic health record.
deficiency slip
indicates what reports are missing or require authentication and enters this information into a computer system that logs and tracks health record deficiencies or maintains a copy of the deficiency slip in a tickler file. A record with deficiencies is called AN INCOMPLETE RECORD.
HIM functions are:
information centered and involve ensuring inforamtion quality, security, and availability.
reassignment (synonymous with misfiles)
involves moving the document from one episode of care to a different episode of care within the same patient record. An annotation should be viewable to the clinical staff so that the reassigned document can be considered if needed
retraction
involves removing a document from standard view, removing it from one record, and posting it to another within the electronic document management system. An annotation should be viewable to the clinical staff so that the retracted document can be consulted if needed.
Government policy maker
is an institutional user of the health record
Feature of clinical decision support systems
is the availability of references - allows the physician to easily look up information without having to rely on memory in prescribing medications or considering a course of treatment.
usual, customary, and reasonable (UCR) charges
method of evaluating providers' fees in which the third party payer pays for fees that are usual in that providers' practice
Serial Unit Numbering System
numbers are assigned in a serial manner, just as they are in the serial numbering system. However, during each new patient encounter, the previous health records are brought forward and filed under the last assigned health record number.
Paper record assembly
organized or assembled after the patient is discharged from the hospital or other setting - each page in the patient record is organized in a pre-established order
The management of high-quality, error free MPI requires constant maintenance that includes: What is first line of defense?
oversight, evaluation, and correction of errors. Prevention of problems should be the front line of defense. Communication back to the department responsible for the errors is key to providing awareness of the importance of the MPI and identifying opportunities for training and workflow issues.
account receivable
records of the payments owed to the organization by outside entities such as third party payers and patients
concurrent review
personnel from the HIM department go to the nursing unit daily (or periodically) to review each patient's record - review occurs concurrently with the patient's stay in the hospital.
Which of the following could be used to determine if someone has the right to view a health record?
photo identification
Amendments and Corrections in EHRs
policies must be in place to assure the integrity of the information contained in the health record as a business record, as a legal health record, and as a patient care communication tool. The facility must have written policies that specify who, when, and how amendments, corrections, and deletions may be made to a health record.
American Medical Recovery and Reinvestment Act of 2009
previously known as the stimulus bill or HR1. the actions related to health information technolgoy are spread throughout the law; however, the bulk of the items ar ein Title XIII--Information Technology; also called Health Information Technology for Economic and Clinical Health Act or HITECH
Data collections
process by which data are collected
Data mining
process of analyzing data from different perspectives and summarizing it into useful information. Analytical tool for large amounts of data. It is the"process of extracting information from a database and then quantifying and filtering discrete, structured data" (AHIMA)
Data Warehousing
processes and systems by which data are archived (saved for future use)
Release of Information (ROI)
protecting the security and privacy of patient information is one of the healthcare institution's top priorities. HIM has responsibility for determining appropriate access to and release of information from patient health records.
Which term is the process of checking individual data elements, reports, or files against each other to resolve discrepancies
reconciliation
The process of assuring that all records of discharged patients have been received by the HIM department for processing is called:
record reconciliation
source systems
refer to other computer systems that feed information into the EHR, which would also need to be corrected according to policy when corrections are made in the EHR.
What is an Enterprise Master Patient index (EMPI)?
references all patients in two or more facilities (ie integrated healthcare delivery system or health information exchange (HIE).
Other HIM functions
research, statistical reporting, cancer registries, trauma registries, and birth certificates
Which term indicates that a document has been removed from standard view?
retraction
Electronic Document Management System
technologies used to provide portions of an electronic health record and does more than manage documents after they are scanned..In a hybrid record environment, the document imaging component is often used to make paper-based records electronically accessible post-discharge.
Commission on Accreditation for Health Informatics and Information Management Education (CAHIIM)
the accrediting organization for educational programs in health informatics and information management
Registration
the act of enrolling
balanced budget refinement act of 1999 (BBRA)
the amended version of the Balanced Budget Act of 1997 that authorizes implementatino of a per discharge prospective payment system for care provided to Medicare beneficiaries by inpatient rehabilitation facilities
discounting
the application of lower rates of payment to multiple surgical procedures performed during the same operative session under the outpatient prospective payment system; the application of adjusted rates of payment by preferred provider organizations
Nosology
the branch of medical science dealing with classification systems
Centers for Medicare and Medicaid Services (CMS)
the division of the Department of Health and Human Services that is responsible for developing healthcare policy in the United States and for administering the Medicare program and the federal portion of the Medicaid program
data currency
the extent to which data are up-to-date
data precision
the extent to which data have the values they are expected to have, Data values should be just large enough to support the application or process
data accessiblity
the extent to which healthcare data are obtainable,Data items should be easily obtainable and legal to access with strong protections and controls built into the process
data definition
the specific meaning of a healthcare related data elementClear definitions should be provided so that current and future data users will know what the data mean. Each data element should have clear meaning and acceptable values,
goal of hybrid record system
to enable retrieval of information to assist healthcare professionals in providing quality patient care and reporting patient outcomes.
What is the purpose of an HIE organization?
to increase the availability of health information to authorized stakeholders in order to improve quality and safety of healthcare delivery across the continuum.
ambulatory surgery center (ASC)
under Medicare, it is a facility that has its own national identifier; is a separate entity with respect to its licensure, accreditation, governance, professional supervision, administrative functions, clinical services, recordkeeping, and financial and accoutnig systems. ahs as its sole purpose the provision of services in connection with surgical procedures that do not require inpatient hospitalization; and meets the conditions and requirements set forth in the Medicare Conditions of Participation
