RHIA Domain 1

Components of __________ record: data on the patient's menstrual history, obstetric history, medical and surgical history, physical exams, nutritional evaluation, behavioral evaluation, lab test results, high risk evaluation, documentation on obstetrical education, and a plan of care based on physical exam.

prenatal

How long must a healthcare entity maintain a certificate of destruction?

permanently

Which type of documentation is this? represents the physician's assessment of the patients current health status after evaluating the patient's physical conditions

physical exam

Components of __________ record: medical, family, social history, vital signs, chief complaint, progress notes, allergies, medication list, HPI, ROS, assessment and diagnosis, plan of treatment

physician office

________ data source: contains information about a patient that has been documented by the professionals who provided care or services to that patient

primary

Consists of a problem list, the history and physical examination and initial lab findings, the initial plan, and progress notes

problem oriented health record

SOAP methodology came from:

problem oriented health record

Which filing system is often used by small clinics and physician offices?

Alphabetic

Another word for outpatient

Ambulatory

Four major purposes for collecting secondary data

(1) Quality, performance, and patient safety (2) Research (3) Population health (4) Administration

Purpose of the legal health record (3)

1. To support decisions made in the course of treating a patient, 2. support documentation for the revenue pursued by payers, 3. and documentation used for legal testimony related to the patient's disease, injury, treatment, the decisions related to it and the response to it

Medicare retention rate of health records

10 years

What kind of entity relationship is this? Patients to hospital beds

1:1

What modifier would you use for a patient who returns during the post-op period and is now complaining of a different problem?

24

Do not use modifier ____ for: post-op period, if there is only an E&M service and no procedure, or if an E&M service with a minimal procedure performed on same day unless can be reported as significant

25

Which modifier? Significant, Separately Identifiable E&M service by the same physician on the same day of the procedure or other service

25

What modifier? Physician performs the professional component only.

26

How long do cancer records have to be maintained according to the FDA?

30 years

How long must health records be retained according to CoP

5 years

Which modifier? Distinct Procedural Service - used to indicate that two or more procedures were performed during the same visit to different sites on the body

59

What modifier? Repeat tests are performed on the same day by the same provider to obtain reportable test values with separate specimen taken at different times

91

Who is Level 1 of CPT updated by? How often?

AMA, annually

a permanent log of all the cases entered into the database

Accession register

What programs does TJC accredit?

Ambulatory, behavioral, critical access hospitals, homeware, hospital, laboratory, nursing care centers, physician offices, and office-based surgery centers

Requires a facility to maintain a single case record for any patient it admits.

CARF

If healthcare organizations want to participate in federal government reimbursement programs, they must at least demonstrate they meet the:

CFCs and CoPs

If an organization meets TJC accredited deemed status survey, they are also deemed to have met the __________ requirements

CMS

federal agency within the US Dept of Health and Human Services. Known for its operational oversight of the Medicare program and in collaboration with state government programs. Also plays an important regulatory role in an organizations medical staff makeup and the content of the medical staff bylaws

CMS

the administrative policy and procedure requirements and operational guidelines (how the policies and procedures are carried out) under which facilities are allowed to take part in the Medicare and Medicaid programs- CMS dictates medical staff bylaws must address certain documentation requirements

CMS Conditions of Participation

all of the patients encounters are filed together in a single location

Centralized unit filing system

The process by which a duly authorized body evaluates and recognizes an individual, institution, or educational program as meeting predetermined requirements

Certification

CARF acronym

Commission on Accreditation of Rehabilitation Facilities

Standards applied to facilities that choose to participate in federal government reimbursement programs such as Medicare and Medicaid

Conditions for Coverage (CFCs)

Purposes of a discharge summary (3)

Ensures continuity of care, provides information to support the activities of the medical staff, provides concise information that can be used to answer information requests

DEEDS

Data Elements for Emergency Department Systems. Recommended data set of hospital based ED

A listing of all the data elements within a specific system that defines each individual data element, standard input of the data element, and specific data length

Data dictionary

An official designation indicating that a healthcare facility is in compliance with the Medicare Conditions of Participation

Deemed status

What is the first step a healthcare entity should take when developing a data dictionary?

Design a plan

software program and supporting hardware that automate and integrate the records management process.

Electronic document management system

What act prohibits healthcare providers from refusing to treat patients or delaying treatment due to the patient not having insurance or not having the ability to pay?

Emergency Medical Treatment and Active Labor Act (EMTALA)

A patient had a radical resection of soft tissue sarcoma of left thigh. What is the root operation?

Excision

When are pharmacy consults required?

For elderly patients who take multiple medications

When must a medical history and physical (H&P) be documented?

For every patient no more than 30 days before or 24 hours after admission to the hospital

How do healthcare providers use the administrative data they collect?

For regulatory, operational, and financial purposes

What is the MEDPAR file frequently used for?

For research on topics such as charges for particular types of care and DRGs.

What document required by TJC should be placed in the patients health record prior to a surgical procedure?

H&P

A major initiative of the AHRQ. Uses data collected at the state level from either claims data from the UB-04 or discharge-abstracted data, including UHDDS items reported by individual hospitals and, in some cases, by freestanding ambulatory care centers

HCUP

Additional privacy regulations on top of HIPAA, breach notification rules & stiffer civil and criminal penalties for security violations

HITECH Act

-oversees most clinical and administrative data such as demographics, reports, claims, and orders -holds patient full medical information from hospital billing to the inpatient ordering system -is the standard generally used in communication between the hospital information system (HIS) and the RIS

HL-7 (health level 7)

HCUP acronym

Healthcare Cost and Utilization Project

Purposes of defining a data dictionary

Help with accuracy of patient data and rate support for data comparison and sharing

Describes body functions and structures, activities and participation

ICF

When is a discharge summary unnecessary?

If the patient's stay is not complicated and lasts less than 48 hours OR involves an uncomplicated delivery or normal newborn (O40)

ICF acronym

International Classification of Functioning, Disability and Health

Which classification system was developed to standardize terminology and codes for use in clinical laboratories?

LOINC

__________ provides names and codes for identifying lab and clinical test results or clinical observation

LOINC

common language (set of identifiers, names, and codes) for identifying health measurements, observations, and documents.

LOINC

LOINC acronym

Logical Observations, Identifiers, Names, and Codes

Overall RAI framework includes

MDS, triggers, utilization guidelines, and resident assessment protocols (RAP)

What setting are these data sets used in? MDS UHDDS OASIS DEEDS

MDS- long term care UHDDS- acute, short, long term care in hospitals OASIS- home health DEEDS- ED

The National Library of Medicine produces two databases of special interest to the HIM professional:

MEDLINE and UMLS (Unified Medical Language System)

Made up of acute-care hospital and skilled nursing facility claims data for all Medicare claims. Consists of this type of data: demographic, data on the provider, information on Medicare coverage for the claim, total charges, charges broken down by specific types of services, ICD-10-CM diagnosis and procedure codes, and DRGs.

MEDPAR

The set of standards defined by the CMS Incentive Programs that governs the use of EHRs and allows eligible providers and hospitals to earn incentive payments by meeting specific criteria

Meaningful Use (MU)

Standards governing the practice of medical staff members; typically voted upon by the organized medical staff and the medical staff executive committee and approved by the facility's board; governs the business conduct, rights, and responsibilities of the medical staff; medical staff members must abide by these bylaws in order to continue practice in the healthcare facility

Medical staff bylaws

Inpatient rehab hospitals and units within hospitals are reimbursed by __________ under a prospective payment system

Medicare

MEDPAR acronym

Medicare Provider Analysis and Review

a strategic plan that identifies applications, technology, and operational elements needed for the overall IT program in a healthcare entity

Migration path

a detailed form with guidelines for assessing residents in long-term care facilities; also details what to do if resident problems are identified

Minimum Data Set (MDS)

A repository of information about health care practitioners, established by the Health Care Quality Improvement Act of 1986

NPDB (National Practitioner Data Bank)

What are the limitations of MEDPAR data for research purposes?

Only contains data about Medicare patients

Components of what report? patients preoperative and postoperative diagnosis, descriptions of the procedures performed, descriptions of all normal and abnormal findings, a description of the patient's medical condition before during and after the operation, estimated blood loess, descriptions of any specimens removed, descriptions of any unique or unusual events during the course of the surgery, name of surgeons and their assistants, date and duration of surgery.

Operative report

What index would be used to compare the number and quality of treatments for patients who underwent the same operation with different surgeons?

Physician index

Who is responsible for ensuring the quality of health record documentation?

Provider

How often is HCPCS updated by CMS?

Quarterly

R-ADT system (acronym and purpose)

Registration-admission, discharge, and transfer system. For tracking in-house patients who have been transferred to a specialty unit

Components of __________ record: patient ID data, pertinent history (including functional history), diagnosis of disability and functional diagnosis, rehabilitation problems, goals, and prognosis, reports of assesments and program plans, reports from referring sources and service referrals, reports from outside consultations and lab radiology orthotic and prosthetic services, designation of a manager for the patients program, evidence of patients/familys participation in decision making, evaluation reports from each service, reports of staff conferences, progress reports, correspondence related to the patient, release forms, discharge summary, follow up reports

Rehabilitation

What is the federal regulated care plan called for skilled nursing facilities?

Resident assessment instrument

___________ normalizes names and unique identifiers for clinical drugs and links its names to the varying names of drugs present in many different vocabularies within the Unified Medical Language (UML)

RxNorm

A classification system designed with electronic systems in mind, currently used for problem lists, ICU unit monitoring, patient care assessments, data collection, medical research studies, clinical trials, disease surveillance, and image indexing.

SNOMED-CT

patient issued unique numerical identifier for every encounter at the facility

Serial numbering system

combination of serial and unit. Patient is issued a new health record number with each encounter but all of the documentation is moved from the last number to the new number.

Serial unit numbering system

What information is necessary to know for coding skin grafts?

Size, type of repair, and recipient site

Meaningful Use Stages

Stage 1: Data capture and sharing Stage 2:Advance clinical processes Stage 3:Improved outcomes

a piece of legislation written and approved by a state or federal legislature and then signed into law by the state's governor, or President of the United States

Statute

files records in straight numeric order based on health record number

Straight numeric filing system

SNOMED-CT acronym

Systematized Nomenclature of Medicine - Clinical Terms

A system of health record identification and filing in which the last digit or group of digits (terminal digits) in the health record number determines file placement

Terminal-digit filing system

Designated multidisciplinary body for the administrative oversight, development, and review of cancer care services at a facility. Communicates directly with the facilities medical board, and its activities and recommendations directly impact programs

The Cancer Committee

An organization that accredits health care organizations and programs

The Joint Commission (TJC)

What government agency has led the development of basic data sets for health records and computer databases?

The National Committee on Vital and Health Statistics

Used for reporting inpatient data in acute care, short-term care, and long-term care hospitals. Minimum set of items based on standard definitions to provide consistent data for multiple users. Required for reporting Medicare and Medicaid patients. Many other health care payers also use most of the UHDDS for the uniform billing system.

Uniform Hospital Discharge Data Set (UHDDS)

Patient is issued a health record number at the first encounter and that number is used for all subsequent encounters.

Unit numbering system

ICF was developed by

WHO

Value used in ICD-10-PCS if there is a character that does not apply to a given code

Z

The ____________ number consists of the first digits of the year the patient was first seen at the facility, with the remaining digits assigned sequentially throughout the year.

accession

Coded information contained in secondary records describing patient identification, diagnosis, procedures, and insurance

administrative data

legal documents that allow you to spell out your decisions about end-of-life care ahead of time.

advance directive

____________ data: include data on groups of people or patients without identifying any particular patient individually. Example: statistics on the average length of stay for patients discharged with a particular DRG

aggregate

Components of __________ record: registration forms including patient ID data, problem lists, medication lists, patient history questionnaires, history and physicals, progress notes, results of consultations, diagnostic test results, misc flow sheets, copies of records of previous hospitalizations/ treatment by other providers, correspondence, consents to disclose information, advance directives

ambulatory

Components of __________ record: history and physical and consent prior to procedure, operative reports and notes, diagnostic and therapeutic documentation, consultations, and discharge notes at conclusion of treatment, discharge follow-up phone calls

ambulatory surgery

Tests and procedures ordered by a physician to provide information for use in patient diagnosis or treatment OR professional healthcare services such as radiology, lab, PT

ancillary services

Systems that serve primarily to manage the department in which they exist, while at the same time providing key clinical data for the EHR

ancillary systems

Ancillary function of the EHR

biomedical research

An accumulation of numeric or alphanumeric representations or codes for exchanging or storing information is a _______________-

code system

Which type of documentation is this? summary of the patients problems from the nurse or other professionals perspective with a detailed plan for interventions. Follows the assessment

care plan

These are examples of ______________: SNOMED CT, ICD, LOINC

code system

__________ coding is completed while the patient is still admitted to the facility whereas ___________ coding is completed after the patient is discharged from the facility

concurrent, retrospective

Consult or referral? _______ is the equivalent of advice. _________ refers to taking over continuum of care

consult, referral

A diagnosis described as "possible" "probable" "likely" or "rule out" is reported as if present for which type of patient records?

inpatient

Primary advantage of using standardized data sets for collecting healthcare information

data can be compared nationally

Term for decision making and authority over data-related matters

data governance

processing of extracting from a database or data warehouse information stored in discrete, structured data format.

data mining

a single database that makes it possible to access data that exists in multiple databases through one single query and reporting interface

data warehouse

process of collecting the data from different data sources within an organization and storing it in a single database that can be used for decision making

data warehousing

factual details aggregated or summarized from a group of health records that provides no means to identify specific patients

derived data

Components of a __________: concise account of patient's illness, course of treatment, response to treatment, condition at time of treatment, and instructions for follow up care

discharge summary

a listing of specific codes (ICD) that link a specific disease or diagnosis to a patient

disease index

exists when person executes a power of attorney which will become or remain effective in the event he or she should later become disabled

durable power of attorney

The RAI is electronically submitted first to ______________ and then to __________

each state health department, CMS

Components of __________ record: patient demographic information, arrival time, means of arrival, name of person bringing the patient, pertinent history of illness, physical findings, diagnostic tests, treatment provided, disposition, condition of patient upon discharge, patient discharge instructions, signatures of patient

emergency department

Primary responsibility of a coder is to

ensure accuracy of coded data

Graphical display of relationships between tables in a database

entity relationship diagram

Skilled nursing facilities are governed by :

federal and state regulations, including Medicare CoP

Which type of documentation is this? snapshot of a patient's status and includes everything from social issues to disease processes as well as critical paths and clinical pathways that focus on a specific disease process or pathway in a long-term care hospital

flow sheet

Records consisting of multiple electronic systems that do not communicate or are not logically architected for record management

hybrid health records

The business of collecting information and selling it to other organizations

information brokering

Components of __________ record: history and physical, consultation reports, physicians orders and progress notes, nursing assessment and progress notes, and discharge summary

inpatient

Components of __________ record: fetal monitoring strips, a record of medications given and stopped, nursing progress notes, events that occur during birth including time and type of delivery

labor and delivery

Components of __________ record: registration forms, personal property list, history and physical and hospital records, advance directives, bill of rights and other legal records, clinical assessments, RAI and care plan, physician's orders, physician's progress notes and consultations, nursing notes, rehab therapy notes, social services, nutritional services, and activities documentation, lab radiology and special reports, discharge or transfer documentation

long term care

What kind of relationship is this? Patients to consulting physicians

many to many

a guide to locating specific demographic information about a patient such as the patient name, health record number, date of birth, gender and dates of service

master patient index

Which type of documentation is this? addresses the patient's current complaints and symptoms and lists his or her past medical, personal, and family history.

medical history

Components of _________: chief complaint, past and present illnesses, family history, social history, and review of body systems must be documented prior to surgery/ procedure requiring anesthesia

medical history and physical (H&P)

Vocabulary of clinical and medical terms used by health care providers to document patient care

medical nomenclature

A data element name is an example of

metadata

Advantages of terminal digit filing system

most effective for facilities with heavy record volume and distributes charts evenly throughout the filing units

Components of __________ record: examination performed upon birth, exam prior to discharge, physical condition immediately after birth, physical condition eval regarding distress and needs of additional care, APGAR, physician's orders, nursing notes, and progress notes.

newborn

Practice or methods that defend against charges questioning the integrity of the data and documents

nonrepudiation

database designed to store different types of data including images, audio files, documents, videos, and data elements

object oriented database

Because a stay for a patient or resident in long term settings can be lengthy, health records are based on :

ongoing assessments and reassessments of the patients needs

a listing of specific codes for procedures or operations performed within the facility

operation/ procedure index

A _________ is completed shortly after admission and upon discharge at an inpatient rehab hospital

patient assessment instrument

A ________________ is completed shortly after admission and upon discharge at an inpatient rehab hospital

patient assessment instrument (PAI)

CMS CoPs and CFCs (conditions for coverage) ensure:

patient care quality, safety, and improvement of clinical outcomes

____________ component is provided by the physician and may include supervision, interpretation, and a written report. The ____________ component includes the provision of all equipment, supplies, personnel, and costs related to the performance of the exam

professional, technical

database that stores data in tables that are predefined and contain both rows and columns of information

relational database

problem-oriented frameworks for additional patient assessment based on problem identification items (triggered conditions) in a long-term care settings

resident assessment protocols (RAPs)

Data derived from the primary patient record, such as an index or a database are considered:

secondary data sources

Principal function of healthcare

serve as the repository of clinical documentation relevant to the care of individual patients

What type of format? Traditional paper format for a hospital patient care record

source oriented

Assisted living facilities are governed by

state regulations

Binary, machine-readable data in discrete fields; data able to be processed by the computer

structured data

The data elements in a patients automated lab result are examples of

structured data

Review of systems is _________ and physical exam is __________ (objective/subjective?)

subjective, objective

A legal document requiring the recipient to bring certain written records to court to be used as evidence in a lawsuit

subpoena duces tecum

Numbering system commonly used in large healthcare facilities

unit numbering

Nonbinary, human-readable data

unstructured data

Most long term care providers do not participate in:

voluntary accreditation programs