c810 wgu

how many days does medicare cover SNF

100

How many hours count as an inpatient service day

24 hours

RxNorm

A clinical drug nomenclature developed by the Food and Drug Administration, the Department of Veterans Affairs, and HL7 to provide standard names for clinical drugs and administered dose forms

In regards to plan-do-check-act (aka: plan-do-study-act.), which of the following occurs during the "check" phase of this process?

A newly implemented processed is reviewed after go-live

Master Patient Index (MPI)

A patient-identifying directory referencing all patients related to an organization and which also serves as a link to the patient record or information, facilitates patient identification, and assists in maintaining a longitudinal patient record from birth to death

Data Back-up Plan/Disaster Recovery Plan

A specification: Make up-to-date back-up copies of all e-PHI. Defines back up, the method of backing up, the location, frequency, and testing

Hospital census includes patient who are still admitted by midnight of the same day and

A&D

A data governance steering committee is formed and tasked with developing the goals of the data governance program. Which generally accepted record-keeping principle is described in this scenario?

ACCOUNTABILITY

What is maintained as a patient moves through different facilities?

ADT--admission/discharge/transfer

Secondary data sources most often represent _______.

AGGREGATE DATA

The data quality model that attempts to include all healthcare data is ____.

AHIMA data quality model

HITECH is a provision of

ARRA

Query-based exchange

Ability for providers to find and/or request information on a patient from other providers, often used for unplanned care

develops standards for exchange of the HIPAA Transaction Code Sets (TCS)

Accredited Standards Committee X12 (ASC X12

patient portal

Allows patient to add information for provider to see

provides an exchange model for clinical documents (such as discharge summaries and progress notes).

CDA--clinical documentation architecture

Requires data for end-stage renal disease

CMS

Two organizations that are in charge of the compliance programs

CMS and OIG

CMI

Case-Mix index (CMI) The average relative weight of all cases treated at a given facility or by a given physician, which reflects the resource intensity or clinical severity of a specific group in relation to other groups in the 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

CPOE

Computerized provider order entry for medication orders, lab services, imaging studies, and other services.

The database design phase where administrators assess user requirements and construct entity-relationship diagrams is called the _________.

Conceptual database design phase

A current trend in maintaining secondary data is to collect _______.

Data in a computer database and query the database as needed for reporting

Which type of statistics use graph, charts and tables?

Descriptive statistics

Which document is used in the acute care settings but not in an ambulatory setting

Discharge summary

A physician is interested in conducting research on herniated intervertebral disk disease. She wants to compare the success of conservative medical care versus surgical intervention. The best source of this information is the ______.

Disease index

The four-level organizational structure proposed for implementing IG is like that of DG implementation:

Executive: Provides the top oversight for the IG program to ensure continuous alignment to the organization's strategy, to provide necessary funding, and to provide general oversight. Strategic: Composed of a multidisciplinary senior leader stakeholder group from key functional areas such as HIM, IT, strategy, legal, compliance, quality, operations, clinical services, and finance. This group establishes the IG charter, provides planning guidance, creates policies and procedures, establishes and advises task forces and work groups, makes decisions based on recommendations from those task forces and work groups, seeks approvals and funding from the executive component as appropriate, tracks accomplishments, and measures and reports progress. Tactical: Composed of various committees, subcommittees, and work groups made up of departmental leaders and subject matter experts. In the ideal organizational structure, a member of the "IG Council" serves as a sponsor for each of the designated task forces and working groups. Operational: Comprising workforce stewards, starting with a network of designated "champions" that are distributed throughout all functional areas and departments of the organization, and growing to encompass the entire workforce. The primary function is to establish "local" IG expertise, support the widespread adoption of IG, and advance the IG culture within every functional area, building a growing capacity of IG competence and talent (AHIMA, 2017).

where can you find the medicare fee schedule

Federal register

RLS is often used in which HIE

Ferdated and hybrid

How does SOAP use in an ambulatory setting

For decision-making process being documented

Requires CEs to develop/implement electronic transaction standards

HIPAA

includes all deaths that occurred in the hospital as well as everywhere else.

Hospital autopsy rate

laboratory data

LOINC --Logical observation identifiers names and codes

Emergency Medical Treatment and Active Labor Act (EMTALA)

Legislation designed to ensure access to emergency medical care regardless of ability to pay

Clinical Laboratory Improvement Amendments (CLIA)

Legislation designed to ensure quality in laboratory settings

Charge Description Master (CDM)

List of billed services, devices, medication

A medical records technician is doing a literature search on the topic of data quality. Which of the following national information retrieval systems would give her the most comprehensive summary of literature on this topic?

MEDLINE

MEDLINE

Medical Literature, Analysis, and Retrieval System Online (MEDLINE) is the best-known database from the National Library of Medicine. It includes bibliographic listings for publications in the areas of medicine, dentistry, nursing, pharmacy, allied health, and veterinary medicine. HIM professionals use MEDLINE to locate articles on HIM issues as well as articles on medical topics necessary to carry out quality improvement and medical research activities.

MEDPAR

Medicare Provider Analysis and Review (MEDPAR) A collection of data form reimbursement claims submitted to the Medicare program by acute care hospitals and skilled nursing facilities that is used to evaluate the quality and effectiveness of the care provided

Largest biomedical database, acute care and skilled nursing facilities, using DRGs

National Library of Medicine (NLM)

NPDB

National Practitioner Data Bank was mandated under the Health Care Quality Improvement Act of 1986 to provide a 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 hospitals against physicians, dentists, and other healthcare providers

Tools that individuals can use to collect, track, and share past and current information about their health or the health of someone in their care, considered as a pt's diaries, no communicating with the providers, just sharing. Maintained by the pts

PHRs

In addition to the diagnosis code, the other essential data element in a disease index is the _____.

PT MEDICAL RECORD NUMBER

Advanced directives (i.e. DNR)

Patients or family members may bring the document to the facility to show the patient's wishes in case of terminal disease, traumatic injury, or cardiac arrest

four types of AHRQ quality indicators

Prevention indications identify hospital admissions that could have been avoided through high quality outpatient care. Inpatient indicators reflect the quality of care inside hospitals, including inpatient mortality for medical conditions and surgical procedures. Patient safety indicators reflect quality of care inside hospitals focusing on potentially avoidable complications and iatrogenic events. Pediatric indicators use one or more of the previous three indicators and adapt them for use with children and neonates.

Aggregate data is secondary data that are created from

Primary data

Rules of Engagement (ROE)

Rules of engagement specify the way that policy makers, data owners, data stewards, and other stakeholders interact with each other. Assignment decision rights is a component of the rules of engagement.

An immunization registry is an example of a _______.

SECONDARY DATA SOURCE

problem list documentation

SNOMED Systemized nomenclature of medicine clinical terminology

What entity is responsible for maintaining vital statistics data?

STATE GOV

SMART goals

Specific, Measurable, Attainable, Realistic, Timely

What kind of data is stored in electronic databases

Structured data

T/F Governance is an enterprise activity that exercises authority across the entire organization

TRUE

T/F The purpose of data quality management is to ensure that data meet characteristics such as accuracy, completeness, accessibility.

TRUE

Data Governance program

The enterprise authority that ensures control and accountability for enterprise data

Why is data governance of the content management function important?

To identify links and relationships among documents can be identified

What is the purpose of business intelligence

To provide access to data for better decision making

The main clinical terminology project of the National Library of Medicine is the _____.

Unified Medical Language System

The net death rate does not include deaths that occurred

Within 48 hours of patient admission

KPI (Key Performance Indicator)

a measure of achievement that can be attributed to an individual, team, or department (measure the effectiveness of a DG program)

Health Statistics

a resource to improve lives, create better/alternative services and promote well-being.

10 characteristics of data quality

accuracy, accessibility, comprehensiveness, consistency, currency, definition, granularity, precision, relevancy, timeliness

data steward teams

are usually cross functional

governance must include what 3 components

authority, decision-making, and accountability.

progress notes

chronological statements about the patient's treatment during their stay?

progress notes

chronological statements about the patient's response to treatment during his or her stay in the facility

ub-04 =

cms1450

Blue Button is an example of which system? (Blue Button - a federal program for VA patients to allow sharing of info)

consumer mediated exchange

characteristics of terminologies and classifications for data standardization

content-concept orientation-concept permanence-nonsemantic concept identifier, polyhierarchy-formal definitions-reject not elsewhere classified-multiple granularities-multiple consistent views-context representation -graceful evolution-recognized redundancy- licensed and copyrighted-vendor neutral-scientifically valid-adequate maintenance self-sustaining-scalable infrastructure and process control

Rules of Engagement (ROE)

creating a mission statement, develop DG goals/metrics, determining funding strategies, developing data rules and definitions, assigning decision rights and accountabilities, establishing controls

Data for processing in EHR is held where?

databases

Healthcare providers meet the basic criteria for HIE Meaningful use by using which of the following?

direct messaging

Which one is used to send immunization record to public health?

direct messaging

medication reconciliation

done when a patient is transferred to another facility

when is a discharge summary not usually needed

for patients who are in the hospital for 48 hours or less (ambulatory settings)

A healthcare organization submits their data to a repository however, data is still maintained within the organization to be updated. What type of HIE structure is this?

hybrid

nursing documentation

icd 10

Stakeholder Analysis

identifies and analyzes the attitudes or opinions of stakeholders

Mission Statement

identifies the fundamental purpose and scope of the DG program?

data governance

includes data models, data security and content management

Information Governance

includes retention and disposal policies

Clinical documentation in a discharge summary in an example of

information

History of Present Illness (HPI)

information gathered regarding the symptoms and nature of the patient's current concern. Detailed chronological description of the development of the patient's illness, from the appearance of the first symptom to the present situation

data security

is the process in which organizations implement protection measures and tools for safeguarding data and information from unauthorized, accidental, or intentional modification, destruction, or use. Data security management includes policies and procedures that address confidentiality and security concerns of organizational stakeholders (for example, patients, providers, and employees), protecting organizational proprietary interests, and compliance with government and regulatory requirements, while accommodating legitimate access needs. The typical functions of data security management that require DG include the following:

must meet the Minimum Data Set (MDS) to meet CMS requirements

long-term care record

MAR

medication administration record--what medications given, time, form of administration, and dosage and strength.

MEDCIN

national standard of medical nomenclature and knowledge base

hospital census does not include

newborns

centralized HIE

offer quick query response and consistency in data accessibility. one repository

Development of a governance program includes the typical management processes of:

planning, organizing, directing, and controlling

Data governance executive steering committee

provides the authorization for the DC program and establish the program's mission

The use of clinical pathways has been stated as reducing

readmissions

data governance

refers to the overall management of the availability, usability, integrity, and security of company data

3 major parts of DGI framework are

rules and rules of engagement, people and organizational bodies, and DG processes

metadata element

time stamp

what data quality characteristics are listed in both ahima data quality model and mri essential principles of documentation?

timeliness and accuracy

direct messaging/DIRECT exchange

used by providers , is viewed as an email in an HTML format, and attachments (labs, CCD, images) are frequently sent as portable document format documents (PDFs). DIRECT exchange is currently used for referrals, discharge summaries sent to primary care physicians, transmission of lab reports to ordering physicians, transmission of continuity of care documents of various kinds, sending immunization data to public health organizations or to report quality measures to the CMS

CEHRT

used to inform providers about the incentives for EHR adoption.

Protocols

written documents that guide a practice.