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
