HIM2211 CH. 6 & 7 other

What is an expander?

Allows transcriptionists to type CHF and full phrase will be automatically spelled out

Clinical Documentation Improvement (CDI) software

Assists in id'ing ways to improve clinical documentation in health record

Which type of encoder mimics a cod ebook?

Automated code book encoder

What system would one use to enter data required by NCHS?

Birth certificate software

Name 4 major sources of external data

CDC, NCHS, AHRQ - AGENCY FOR HEALTHCARE RESEARCH AND QUALITY, JOINT COMMISSION

Give example of secondary data

Cancer registry

Name 2 common registries-

Cancer registry and trauma registry

Life expectancy information would come from?

Cancer registry software

Give example of secondary data source

Cancer registry, master patient index and disease index

Which system would tell a physician that they need to sign an operation report?

Chart deficiency

Which system tracks location of paper medical record?

Chart locater

What is a trauma registry?

a data retrieval system for trauma patient information, used to evaluate and improve the trauma system. Tracks pt from initial trauma to death.

External data

Come from outside the facility and can be used to compare the facility with other similar facilities.

Primary data source

Comes directly from the source of the data

grouper

Computer program that uses specific data elements to assign patients, clients, or residents to groups, categories, or classes.for ms-drg which is most common.

What organization sponsored ORYX?

JOINT COMMISSION

What is the biggest advantage of using an encoder?

Prompts

The system used to notify requesters of invalid authorization is?

ROI

Which system should one use to print out a report of people who have not paid for copies of records sent to them?

ROI

What system acts as a historical database of of all requests processed and used to generate reports?

ROI system

HIM SOFTWARE SYSTEMS

ROI, ENCODER AND GROUPER SYSTEMS, CANCER REGISTRY,CHART LOCATOR, BIRTH CERTIFICATE, CHART DEFICIENCY, TRANSCRIPTION,HEALTHCARE QUALITY INDICATOR SYSTEM, DICTATION SYSTEM,COMPUTER ASSISTED CODING, CLINICAL DOCUMENTATION IMPROVEMENT.

What is a registry used for?

Records data on pts who meet inclusion in the registry

What does a chart deficiency system do?

Records documentation not recorded and tracked and alerts physician to correct and return

Which software tracks patients who meet criteria for inclusion for specific disease or treatment?

Registry

What is rules based encoder?

Requires user to type name or portion of the diagnosis or procedure

Electronic Discovery (e-discovery) audit trails

The collection, preparation, review, and production of electronically stored information for use in criminal and civil legal actions and proceedings.

Who can develope birth certificate software

State or outside vendor

Trauma reporting provides?

Stats on cause of injury, type of injury and other descriptive stats

What term describes where you enter the locations that a record can be checked out to is?

Table

What is NLP- natural language processing

Technology that converts human language, structured or unstructured, into data that can be translated and manipulated by computer systems.

,,what is a chart deficiency?

A record arriving at HIM department missing vital information

What is an encoder?

A computer software that helps coding professional assign appropriate codes for diagnosis.

Name 2 critical aspects of the quality indicator system-

Abstracting and reporting

What is the healthcare quality indicator system?

Abstracting system that records info about the patient and the care provided to pt.

example of metadata

Creation date, date last accessed, date received

Metadata are ________.

Data about data

Secondary Data Sources

Data taken from primary source and abstracted into another database or registry

What does ROI system do?

Designed to manage the processing of requests for protected health information received and processed by HIM dept.

Chart locater system

Designed to track paper medical record

What type of system would a physician use if he speaks into phone and gives a summary of PTS care which is later transcribed?

Dictation

What computerized system is designed to help assign the proper code?

Encoder

Automated code book encoder

Encoder that lists diagnoses and procedures in alphabetic order like an index in CPT and ICD 10 CM

Which system would you use if you typed in EGD and esophagogastroduodenoscopy was spelled out?

Expander

Give example of a database that contains national data on costs of care

External data

What system should be used to assign diagnosis and procedure codes?

Grouper

Which system should be used to assign diagnosis and procedure codes?

Grouper

Who mandates tracking of disclosure reports?

HIPAA

To enter the number of units of blood received during a recent hospitalization what would you use

Healthcare quality indicator

The encoder and grouper are usually linked to what?

Hospitals financial system

Give examples of data collected for healthcare quality indicator systems-

How many units of blood, nosocomial infections, physician, nursing unit,apparently score.

What Information does a ROI system provide the him mgmt team?

Information requests not processed, requests that have been processed, turnaround time, revenue collected, accounts receivable, productivity of each staff member, overall productivity, list of frequent requesters, multiple customized letters.

An example of primary data source?

Medical record as it comes directly from the pt

Chart locater system used for?

Multiple purposes, id's most user requests of records, productivity tracking, I'd of trends in volume of record retrieval's, id's areas of facility with most late record returns.

What external data source would one use to find data on birth within the US?

NCHS-NATIONAL CENTER FOR HEALTH STATISTICS

What information is frequently populated in the ROI system?

Name and medical record number

How long should disclosure of information be kept?

Per HIPAA requirements, information must be kept for minimum of 3 yrs.

Example of rules based encoder -

Pneu- encoder suggests pneumonia or pneumonitis

Examples of data elements for cancer registry

Site of cancer, type, treatment received, date of last contact, # of lymph nodes involved, behavior type, DOA, grade of neoplasm, size, phys name, ICD-0 code

Give examples of data elements for trauma registry-

Site of injury, type, how it happened, date of injury,time, work-related, ICD-10-CM & PCS, SAFETY EQUIPMENT, REGISTRY NUMBER,autopsy performed, met arrival time.

What is birth certificate information system?

Software that reports births occurring in healthcare facility to state health agency.

What is a registry?

Tracks conditions such as cancer, diabetes,traumas and transplants

What is a database management system (DBMS)?

Tracks disclosures made throughout healthcare organization for reporting purposes.

Is data abstracting the key functionality of healthcare quality indicator system?

True

What is CAC COMPUTER ASSISTED CODING?

Utilizes natural language processing to analyze clinical data to identify diagnosis/procedures and assign appropriate codes.

What is key focus of dictating a report?

Workload

Which system collects TNM stage?

cancer registry software

Internal Data

comes from within the healthcare facility and includes both administrative and clinical data

ROI

release of information

Cancer registry information system

tracks very detailed information regarding diagnosis and treatment about the patient's cancer from the time of diagnosis to the patient's death