RHIA Exam 1 and Domain 1 & 2

Income statement

A financial statement that reports a company's revenues and expenses and resulting net income or net loss for a specific period of time. Ex. for the fiscal year.

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

A patient was admitted to the hospital and diagnosed with Type 1 diabetic gangrene. What is the correct code assignment?

E10.52 Type 1 diabetes mellitus with diabetic peripheral angiopathy with gangrene

shift differential

Extra pay received by employees for working a less-than-desirable shift (e.g., evenings, late nights or weekends).

According to the records kept on filing unit performance over the past year, the filing unit has filed an average of 1,000 records per day. You have three full-time equivalent record filers in the dept. who are productive 88% of each workday (that is, 12% unproductive or 12% PFD). Based on this info., what is the average number of records filed per productive hour in the file unit as a whole?

First calculate the number of productive hours in a day: 88% x 8 hours = 7.04 hours/day. Then divide the 1,000 records/7 hours = 142.9 or 143 charts/hour for the three filers.

Documenting the full depth and breadth of data use in a healthcare entity requires:

HIM professional must first Identify the needs of data consumers and who the data consumers are. This involves making a list of all the internal and external consumers. Ask the data consumer how they use the data rather than what their needs are. Biedermann & Dolezel, 167-168

Episode-of-care reimbursement

Healthcare payment method in which providers receive one lump sum for all the care they provide related to a condition or disease.

Current Ratio Formula

Helps measure the ability of the company to pay its short-term obligations with short-term assets. Current Ratio = Current Assets / Current Liabilities Ex: 4,000,000/5,000,000 = 4/5 = 0.8 The current ratio indicates that for every dollar of current liability, $0.80 of current assets could be used to discharge the liability, which is not enough because it is not at least $1.

Logical Observational Identifiers Names and Codes (LOINC)

a well-accepted set of terminology standards that provide a standard set of universal names and codes for identifying individual laboratory and clinical results

Metadata are ________.

data that describe data in databases. data element name, data type, and field length are examples of this kind of metadata.

Computer output laser disk/enterprise report management (COLD/ERM) technology

electronically stores, manages, and distributes documents that are generated in a digital format and whose output data are report-formatted and print-stream originated. COLD/ERM technology not only electronically stores the report-formatted documents but also distributes them with fax, e-mail web, and traditional hard copy print processes.

Nonexempt employees

employees covered by the fair labor standards act (FLSA) requirements for overtime pay. Provisions to this act, for example, cover minimum wage, overtime pay, child labor restrictions, and equal pay for equal work regardless of sex.

workforce

employees, volunteers, trainees, and other persons performing functions on behalf of covered entities and business associates, whether paid or not Biedermann and Dolezel, 354

facility directory

example of a disclosure that the patient has the right to agree or object. facility directory of patients being treated that would allow callers to get general information about condition, name, location in the facility.

According to Joint Commission Accreditation Standards, which document must be placed in the patient's record before a surgical procedure may be performed?

except in emergency situations, every surgical patient's chart must include a report of a complete history and physical before the surgery is to be performed

age is the independent variable; ancillary charges is the dependent variable

if an analyst wishes to predict future ancillary charges for hip replacement patients based on the age of the patient, which of the following is a correct statement?

Application testing

is the process of trying out various sequences of input values and checking the results to verify that the application works as it was designed as written in the RFP or contract. Ex. running a mock query

Name of element, definition, application in which the data element is found, locator key, ownership, entity relationships, date first entered system, date terminated from system, and system of origin are all examples of:

metadata

Database

A collection of data tables. The most common form of a data table found in practice is a tab or worksheet within a spreadsheet.

Boolean search

A Boolean operator is a computer-programming term for conjunctions like, "AND," "OR," and "NOT" which can be used to construct more complex search conditions. Usually found under the advanced options. In this case, the user could search a diagnosis cerebral infarction "or" cerebral hemorrhage and find all of them.

proportion

1. The relationship of one thing to another in size, amount, etc. 2. Size or weight relationships among structures or among elements in a single structure. 3. A part, share, or number considered in comparative relation to a whole.

Sponsor

A person or group who provides resources and support for the project, program, or portfolio and is accountable for enabling success. Every project has an identified sponsor. The sponsor is the facility employee with the most vested interest in the project's success. It is good practice to select someone who has responsibility for the organization's dept.s, divisions, and personnel that will be affected by the project.

work measurement

A process of analyzing jobs for the purpose of setting time standards. A process of studying the amount of work accomplished and the amount of work it takes to accomplish it. It involves the collection of data relevant to the work.

Integrated Delivery System (IDS)

A system that combines the financial and clinical aspects of healthcare 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. The collaboration integration of healthcare providers with the goal of the IDS is a seamless delivery of care along the continuum of care, so one bill would be generated.

Application Service Provider (ASP)

A third-party service company that delivers, manages, and remotely hosts standardized applications software via a network through an outsourcing contract based on fixed, monthly usage, or transaction-based pricing. In an ASP model, there is less upfront capital outlay and fewer IT staff required in-house.

informed consent

A written agreement to participate in a surgery made by an adult who has been informed of all the risks that participation may entail. The surgeon is the healthcare provider who would discuss the consent for treatment with the patient. Basic elements of an informed surgical consent should include the purpose of the proposed procedure, any risks associated with the procedure, and if noninvasive treatment alternatives might be considered.

Indicator

An indicator is a performance measure that enables healthcare organizations to monitor a process to determine whether it is meeting process requirements. Monitoring blood sugars on admission and discharge is an indicator of the quality of care delivered to the diabetes patient during the stay

You want to graph the average length of stay by sex and service for the month of April. Which graphic tool would you use?

Bar graph. Bar charts are used to display data from one or more variable and are used for nominal or ordinal variables. In this case, you would be displaying the ALOS by service and then within each service have a bar for each gender

External Change Agents: Advantages

Bring an outsider's objective view Preferred by employees due to their impartiality. Ex.:Benchmarking the healthcare entity against other entities.

Treatment, Payment and Operations (TPO)

Conditions under which protected health information can be released without consent from the patient. TPO are functions of a covered entity that are necessary for the CE to successfully conduct business. Therefore, many of the Privacy Rule's requirements are relaxed or removed where PHI is needed for purposes of TPO

Full-service contracting

Contracting for staffing to handle a complete function

Boolean data

Data that can have only two possible answers: true (1) or false (0).

Derived data

Data that have been selected, formatted, and aggregated for end-user decision support applications. Data that consist of factual details aggregated or summarized from a group of health records that provide no means to identify specific patients.

The HIPAA Privacy Rule is enforced by:

Department of Justice - Office of Civil Rights

A dietary department donated its old microcomputer to a school. Some old patient data were still on the microcomputer. What controls would have minimized this security breach?

Device and media controls. HIPAA requires the implementation of policies and procedures for the removal of hardware and electronic media that contain ePHI into and out of a facility. In this example, this was a security breach from lack of wiping data from devices.

The term used to describe multiple health record numbers is:

Duplicates

MPI errors

Duplicates and overlays can reveal procedural problems that contribute to the creation of errors. HIM dept. identifies the errors they must share that info. with the registration staff to make them aware of the problem.

How are Hospital Compare measures used by CMS?

Hospitals that report all measures receive the full payment update. Hospital compare reports on 139 measures of hospital quality of care for heart attack, heart failure, pneumonia, and the prevention of surgical infections. The data available at Hospital Compare is reported by hospitals to meet the requirements of the Medicare Value Based Purchasing program.

The Privacy Rule requires a covered entity to arrange a convenient time and place for the individual to inspect his or her record...

However, the covered entity also has an obligation to protect the record's integrity. Therefore, it is within the covered entity's right to provide an authorized HIM staff member to be present when the individual reviews the record

many-to-many relationship

In databases, a relationship in which one record in Table A can relate to many matching records in Table B, and vice versa.

query format

It is recommended that the healthcare entity's policy address the query format. A query generally includes the following information: patient name, admission date or date of service, health record number, account number, date query initiated, name and contact information of the individual initiating the query, and statement of the issue in the form of a question along with clinical indicators specified from the chart (for ex., history and physical states urosepsis, lab reprts WBC of 14,400, emergency dept. report fever of 102F).

record locator service

Links systems and uses indexing and identification for HIE patients to access info. The RLS does not provide info. about the record, it merely points to where it might be found.

Expert determination (apply statistical or scientific principles to ensure there is a very small probability of any identification of the individuals) & Safe Harbor (removal of 18 types of identifiers and requires that there be no actual knowledge that the residual data can identify an individual).

Office of Civil Rights (OCR) sanctioned HIPAA Privacy Rule DE-identification methods Biedermann and Dolezel, 359-361

a part of HIPAA that outlines standards for maintaining patient confidentiality and safeguarding financial and administrative data during electronic transfer.

Privacy Rule. The privacy rule uses six years as the period for which Privacy Rule-related documents must be retained. The date the document was created or the last effective date of the document, including policies and procedures, the notice of privacy practices (NPP), complaint dispositions, and other actions, activities, and designations must be documented per Privacy Rule requirements.

Fee-for-service (FFS)

Providers are paid for each service performed base off the charges assigned to each separate services that were performed for the patient, as opposed to capitation. Fee schedules are an example of fee-for-service. Chargemasters are used to list the individual charges for every element entailed in providing a service (for ex., surgical supplies, surgical equipment, room and board, nursing care, respiratory therapy, pharmaceuticals, medical equipment, and so on).

Qualitative standard

Service standards in the context of setting expectations for how well or how soon work or a service will be performed. Specify the level of service from a function such as accuracy rate, error rate, turnaround time, and response time. To properly communicate performance standards, mgr.s need to make the distinction between quantitative and qualitative standards and identify examples of each for the health information system (HIS)

The HIPAA Privacy Rule

Sets a minimum (floor) of privacy requirements. As long as state laws or regulations or the physician does not state otherwise, competent adult patients have the right to access their health record

flat file

Spreadsheet. Simple database program whose records have no relationship to one another.

The SOAP form of progress notes

Subjective, Objective, Assessment, Plan (SOAP) notes are part of the problem-oriented medical records (POMR) approach most commonly used by physicians and healthcare professionals. SOAP notes are intended to improve the quality and continuity of client services by enhancing communication among healthcare professionals.

If an analyst is studying wait times at a clinic and the only list of patients available is on hard copy, this technique would make it easiest.

Systematic sampling. A procedure in which the selected sampling units are spaced regularly throughout the population; that is, every fifth or every tenth member is selected randomly. Should not be sorted in an order that might bias the sample

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 the 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 by the total number of patients discharged.

Health Record Matrix

The documentation that comprises the LHR may exist in separate and multiple paper-based or electronic systems, which complicates the process of pulling the entire LHR together in response to authorized requests to produce the complete patient record. Once the LHR is defined, it is best practice to create a health record matrix that identifies and tracks the physical location of each paper document and the source of each electronic document that constitutes the LHR. In addition to defining the content it is best practice to establish a policy statement on the maintenance of the LHR.

Corporate Negligence

The failure of an organization to exercise the degree of care considered reasonable under the circumstances that resulted in an unintended injury to another party. The Darling v. Charleston Community Hospital case of 1965. In this case, the court ruled specifically that hospital governing boards have a duty to institute a proper standard of care owed the patient, which is to ensure patient's safety and well-being while at the hospital.

Minimum Data Set (MDS) for Long-Term Care

The instrument specified by the Centers 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. A component of the resident assessment instrument (RAI) and used to collect info. about the resident's risk factors and to plan the ongoing care and treatment of the resident in the long-term care facility.

Profitability Index (PI)

The present value of an investment's future cash flows divided by its initial cost. Also called the benefit-cost ratio. A profitability index helps the organization prioritize investment opportunities. For each investment, divide the present value of the cash inflows by the present value of the cash outflows. Ex: radiology cash inflow; 2,000,000 present outflow; 500,000 = 2,000,000/500,000 = 4 The profitability index is 4

champion

The project champion is an executive in the organization who believes in the benefits of the project and advocates for the project. Could be the HIM mgr., the director, or the chief operations officer (COO)

Liver functions

This organ plays a major role in metabolism and has a number of functions in the body, including glycogen storage, decomposition of red blood cells, plasma protein synthesis, hormone production, and detoxification. It lies below the diaphragm in the abdominal-pelvic region of the abdomen. It produces bile, an alkaline compound which aids in digestion via the emulsification of lipids. The liver's highly specialized tissues regulate a wide variety of high-volume biochemical reactions, including the synthesis and breakdown of small and complex molecules, many of which are necessary for normal vital functions.

root operation: resection (T)

What operation does: takes out some or all of a body part Objective of procedure: cutting out or off without replacement Procedure site: all of a body part Example: total mastectomy

Root Operation: Excision (B)

What operation does: takes out some or all of a body part Objective of procedure: cutting out or off without replacement Procedure site: some of a body part Example: breast lumpectomy

Gross death rate a.k.a. hospital death rate

[# inpatient deaths (including NB) in a period / # discharges (including NB)] x 100

Pareto Chart

a bar chart on which factors are plotted along the horizontal axis in decreasing order of frequency. The highest-ranking item is listed first, followed by the second highest, down to the lowest-ranked item. A Pareto chart is a kind of a bar graph that uses data to determine priorities in problem solving. The Pareto principle states that 80% of costs or problems are caused by 20% of the patients or staff.

Pareto Chart

a bar graph whose bars are drawn in decreasing order of frequency or relative frequency. a king of bar graph that uses data to determine priorities in problem solving. The Pareto principle states that 80 percent of costs or problems are caused by 20 percent of the patients or staff.

Bar graph

a diagram in which the numerical values of variables are represented by the height or length of lines or rectangles of equal width.

Digital signature

a digital signature is a digitized version of a handwritten signature that differs from an electronic signature in that it uses handwritten signatures on a pen pad.

digital signature

a digital signature is a digitized version of a handwritten signature. A digitized signature differs from an electronic signature in that it uses handwritten signatures on a pen pad. The actual written signature is converted into an electronic image. Digitized signatures are acceptable if allowed by state, federal, and reimbursement regulations.

incident report

a means of documenting problem events within a hospital or other medical facility. Hospitals strive to keep incident reports confidential, and in some states, incident reports are protected under statutes protecting quality improvement studies and activities. Incident reports themselves should not be considered a part of the health record. Because the staff member mentioned in the record that an incident report was completed, it will likely be discoverable as the health record is already a discoverable document.

Critical Path Method (CPM)

a project-management tool that illustrates the relationships among all the activities involved in completing a project and identifies the sequence of activities likely to take the longest to complete. The path with the greatest total duration time is called the critical path and represents the longest amount of time required to complete the total project. The critical path in this project will take 23 days

Registration or patient access

a review of the identified duplicates and overlays often reveals procedural problems that contribute to the creation of errors. HIM depts. may be the hub of identifying, mitigating, and correcting MPI errors, but that info. is often not shared w/other departments within the healthcare organization. After identifying procedural problems that contribute to the creation of the MPI errors, which dept. should the MPI manager work with to correct these procedural problems?

balanced scorecard methodology

a technique for measuring organization performance across the four perspectives of customer, financial, internal processes, and learning and growth

a physician query may not be appropriate in this instance

acute respiratory failure in a patient whose lab report findings appear to not support this diagnosis. In situations in which the provider's documented diagnosis does not appear to be supported by clinical findings, a healthcare entity's policies can provide guidance on a process for addressing the issue without querying the attending physician.

administrative safeguards

administrative policies and procedures designed to protect electronic health information outlined by the HIPAA Security Rule, are people-focused, and include requirements such as training and assignment of an individual responsible for security

Discrete data

are whole numbers that may or may not be related, so a bar graph is the best data display tool to use to display discrete categories

determining the components of the legal health record

as the first step, develop a list of statutes, regulations, rules and guidelines regarding the release of the health record.

you are the coding supervisor and you are doing an audit of outpatient coding. A patient was seen in the outpatient department with a chronic cough and the record states, "rule out lung cancer." What should have been coded as the patient's diagnosis?

chronic cough; outpatient coding guidelines do not allow coding of possible conditions as a diagnosis for the patient. Do not code diagnoses documented as "probable," "suspected," "questionable," "rule out," "working diagnosis," or other similar terms indicating uncertainty. Rather , code the condition(s) to the highest degree of certainty for that encounter or visit, such as signs, abnormal test results, or other reasons for the visit.

clustering

clustering is the practice of coding or charging one or two middle levels of service codes exclusively under the philosophy that, although some will be higher and some lower, the charges will average out over an extended period

Record retention program

conducting an inventory of the facility's records, Determining the format and location of record storage, Assigning each record a retention period, Destroying records no longer needed

Root Operation: Division

cutting into a body part without drawing fluids or gases from the body part in order to separate or transect a body part

Capitated rate

method of payment where insurance reimburses providers on a fixed, per capita amount for a period. Per capita means per head or per person. A common phrase in capitated contracts is per member per month (PMPM). The PMPM is the amount of money paid each month for each individual enrolled in the health insurance plan. Capitation is characteristic of HMOs. Ex. Dr. gets $15 per visit. Saw 300 pts in last month, insurance pays Dr. $4,500.

Strong matrix organization

project managers are not functional staff members assuming the role of project manager, but rather are project manager specialists reporting to a manger of project management; it is very similar to the balanced matrix but includes a department of project managers

anonymity (an ah nim ah tee) in research refers to

protecting confidentiality - even researchers should be unable to link data and participants. Anonymity demands that the researcher cannot link the response and the responder because the code would link the respondents to their data, so their data would no longer be anonymous

While the focus of inpatient data collection is on the principal diagnosis, the focus of outpatient data collection is on:

reason for encounter

Data tables include:

records or rows and fields or columns

Breach Notification Rule

requires covered entities and business associates to establish policies and procedures to investigate an unauthorized use or disclosure of PHI to determine if a breach occurred, conclude the investigation, and to notify affected individuals and the secretary of HHS within 60 days of breach discovery

Workforce Security Standard

requires the organization to ensure that those with a legitimate need to access info. are able to do so while at the same time ensuring that those workforce members who do not have a legitimate need to that info. are prevented from gaining access. The three specifications include: authorization and supervision, workforce clearance procedures, and termination procedures

Physician advisor (PA)

reviews health records for various reasons, including medical record reviews, utilization reviews, quality reviews, surgical case and tissue reviews, other pathological reviews, and a host of blood and laboratory reviews for various medical staff and hospital committees. The HIM mgr. must continuously promote complete, accurate, and timely documentation to ensure appropriate coding, billing, and reimbursement. This requires a close working relationship with the medical staff, perhaps through the use of a physician advisor. Physician advisors assist in educating medical staff members on documentation needed for accurate billing. The medical staff is more likely to listen to a peer than to a facility employee, especially when the topic is documentation needed to ensure appropriate reimbursement.

sampling

sampling is the recording of a smaller subset of observations of the characteristic or parameter, making certain, however, that a sufficient number of observations have been made to predict the overall configuration of the data. Sometimes, the organizational characteristics or parameters about which data are being collected occurs too frequently to measure every occurrence. In this case, those collecting the data might want to use sampling techniques.

To reduce the effect of a server crash in an EHR environment, it is advisable to:

set up a redundant systems. To achieve availability, an EHR must have full redundancy as well as backup and network redundancy. This means that there is a duplication of all data, hardware, cables, or other components of the system. Should the primary server crash, the system switches over to the second server and can continue processing

Data content standards are used to:

share data in a way that users interpret data in same way

abbreviations in the health record:

should have only one meaning

Resident Assessment Protocols (RAPs)

structured, problem-oriented frameworks for organizing minimum data set (MDS) information and additional clinically relevant information about an individual that identifies medical problems and forms the basis for individual care planning. RAPs form a critical link to decisions about care planning and provide guidance on how to synthesize assessment info. within a comprehensive assessment. The triggers target conditions for additional assessment and review, as warranted by the MDS response. The RAPs guidelines help facility staff evaluate triggered conditions. Although RAP terminology is still in common use, CMS now uses the term care area assessment (CAA) process to describe this concept.

root operation: extirpation

taking or cutting out solid matter or material from a body part; examples are thrombectomy, removal of foreign body, choledocholithotomy, removal of calculus, or it may be a by-product of a biological function, for example, a blood clot or a plaque deposit in a blood vessel.

Computer output laser disk/enterprise report management (COLD/ERM) technology

technology that electronically stores, manages, and distributes documents that are generated in a digital format and whose output data are report-formatted and print-stream originated. COLD/ERM technology not only electronically stores the report-formatted documents but also distributes them with fax, e-mail, web, and traditional hard copy print processes

Conceptual skill

the ability to think analytically and solve complex problems. These skills are greatest at the top level of management and include such competencies as visioning the organization, planning, decision making, problem solving, creativity, and conceptualizing the connections among parts of a complex organizational system or "systems thinking".

The legal health record for disclosure consists of:

the data, documents, reports, and information that comprise the formal business records of any healthcare entity that are to be utilized during legal proceedings

A possible justification for building an information system in-house rather than purchasing one from a vendor is that:

the facility has development teams they do not want to give up

incidence rate

the number of new cases of disease within a population during a specific period. Incidence means rate of occurrence. Measure of the probability of occurrence.

mask

the use of the mask tells the database what format to use to display the number. the data dictionary may also control if a mask is used and if so, what form it takes. Ex: the social security number of 123456789 could be entered and it appears in the system as 123-45-6789.

financial data

type of data exemplified by the insured party's member identification number, eligibility and benefits info., healthcare claims; details about the patient's occupation, employer, and insurance coverage collected at the time of treatment. Healthcare providers use this data to complete claims forms that will be submitted to third-party payers.

Entity Relationship Diagram

used to clarify table relationships in a relational database

Notice of Privacy Practices (NPP)

written document describing a covered entity's principles and procedures related to the protection of patients' health information. For fundraising activities that benefit the CE it is permitted to use and disclose, without authorization, demographic info. and dates healthcare was provided to the pt., but prior authorization is required for info. based off the pt.'s diagnosis.