HITT 2149-RHIT Competency Review

Best way to ensure the completeness of the health record:

Review each patient's health record concurrently to ensure the H&P are present.

Health record analysis

Review of patient records to ensure the quality and completeness of clinical documentation, generally performed after the patient is discharged.

Quantitative analysis

Review of the health record to determine completeness and accuracy; determine if everything is there or if there is any missing reports, forms or signatures. Has 2 types of review: concurrent and retrospective.

Prospective review

Review that takes place prior to elective procedures and missions.

Data currency example

Reviewing & updating patient medication at each patient encounter to remove meds that are no longer being taken and add any new meds.

Qualitative analysis

Reviewing a record to ensure that standards are being met; Monitoring the quality of the document, review legibility, timeliness of documentation, use of abbreviations & other documentation standards.

Operation index

A list of the operations & surgical procedures performed in a healthcare facility, which is sequenced according to the code numbers of the classification system in use.

Data set

A list or recommended data elements with uniform definitions that are relevant for a particular use or are specific to a type of healthcare industry.

Disease index

A listing in diagnosis code number order of patients discharged from the facility during a particular time period.

Coding policies should include:

AHIMA Code of Ethics, AHIMA Standards of Ethical Coding, Official Coding Guidelines, applicable federal & state regulations, internal documentation policies requring the presence of physician documentaiton to support all coded diagnosis & procedure code assignments.

Example of a required critical conversation

Abigail placing Daniel on probation due to continuing problems with decreasing coding producivity and coding.

Example of a legal concern regarding the EHR:

Ability to subpoena audit trials

When 2 or more diagnosis equally meet the criteria for principal diagnosis:

According to coding guidelines any one of the principla diagnoses may be sequenced first.

Record-over-record method

Accuracy calculation that divides the number of records where there was no change in APC or DRG assignment by the total number of cases reviewed that considers each health record coded incorrectly as one error.

Characteristics of data quality

Accuracy, accessibility, comprehensiveness, consistency,currency, definition, granularity, precision, relevancy and timeliness.

Effective form desgin principles for an EDMS

All forms should contain a unique number, original and recised dates, concise title, facility's name and logo, clincial forms, patient identificaiton information on every page, signature line, character reader codes and barcodes in the upper-left hand corner, best size= 8.5 by 11 inches, form colors should be black and white (use of colored paper or ink, shading of text should be minimized or eliminated), vertical and horizontal lines, sufficient space, titles for boxes and fields, paper=20 to 24 pounds, type size=no smaller than 9 points=lowercase letter and 10 points=uppercase letters.

HITECH breach notificaiton requirements

All individuals whose information has been breached must be notified without unreasonable delay and not more than 60 days, if 500 or more individuals are affected they must be individually notified immediately and media outlets must be used as a notification mechnaism & the Secretary of HHS must specifically be notified.

Local coverage determination (LCD)

Are educational materials that assist facilities and providers with correct billing and claims processing, within is a listing of ICD-10-CM codes that indicate what is covered and what is not covered.

Biggest threat to the security of healthcare data:

Are employees.

Network safeguard

Are essential to prevent the threat of hackers and protect against intruders, corruption during transmission withint & external to the organization.

Descriptions

Are human-readable representations of concepts.

Administrative safeguards

Are policies & procedures required by HIPAA that address the management of computer resources & security.

Reported performance data

Are regularly analyzed for variance.

Patient care managers

Are responsible for the overall evaluation of services rendered for their particular area to identify patterns & trends, they take details from individual health records and put all the information together in one place.

Patient care outcomes

Are reviewed to improve the safety & quality of care and to identify issues related to medical necessity for treatment and appropriateness of care.

APC payments

Are subject to payment reductions when multiple procedures are performed during the same visit; when there are no additioanl procedures then the status indicator does not affect payment & the facility will receive 100% payment.

JC data collection requirements

Areas included are medicaiton management, blood & blood product use, restraint & seculsion use, behavior management & treatment, operative and other invasie procedures & resuscitation and its outcomes.

Secondary data is used for multiple reasons including:

Assisting researchers in determining effectivness of treatments.

Data accessibility

Assure the data is available when needed & easy to obtain while implementing proper precautions & safeguards to protect the information.

Variance

Average of the squared deviations from the mean.

Discharged not final billed report (DNGB)

Billing report that is a daily report used to track the many reasons that accounts may not be ready for billing; accounts that have not met all facility-specified crtiera for billing are held and reported on this daily tracking list.

Noncustodial partients rights to medical records

By law, a parent not granted custody of a minor child has the same rights as the cusodial patient to the child's academic, medical, hospital and other health records unless otherwise ordered by the courts.

Combat insufficient documentation

By performing a root cause analysis of records denied for insufficient documentation & then develop a plan based on the findings.

Way a supervisor determines whether the ROI staff members are working at optimal output:

By setting productivity standards for the area, and review results on a regular basis.

How IPPS cacluates CMI

By taking the sum of all relative weights then dividing them by the total number of discharges.

Determination of excision of skin lesion codes

By the body area from which the excision occurs, diameter of the lesion, & the margins excised as described in the operative report.

Owner of hospital health records, x-rays, lab and consultation reports:

By the healthcare organization

Maintain privacy for a high profile patient

By using access logs that are checked daily to determine whether all access to this patient's information by workforce is appropriate.

Continuing education for coders

Can be accomplished without sending staff to costly external seminars or workshops. Good internal suggestions include physician from the medical staff can be asked to present clinical topics to coders, coding managers can use member resources form AHIMA to educate coders & can have coders research clinical topics to present to each other.

Speech recognition

Can be very effective in certain situations when data entry is fairly repetitive and the vocabulary used is fairly limited.

Adverse effects

Can happen when a medication is correctly prescribed and correctly taken.

Record cusodian

Can testify about identificaiton of the record as the one subpoenaed in a legal proceeding is attempting to admit a health reocrd as evidence.

Incident reports in legal matters

Cannot be discovered event if it's mentioned in a discoverable document.

A hospital can monitor its performance under the MS-DRG system by monitoring its ______.

Case-mix index (CMI)

Examples of structured data

Cheack boxes, drop-down boxes, and radio buttons.

Compliance Officer

Checks the written standards of conduct, policies, procedures & audits that address the areas of potential fraud.

Audit trail

Chronological set of computerized records that provides evidence of information systems activity (logins & logouts, file accesses) used to determine security violations; a record that shows who has accessed a computer system, when it was accessed & what operations were performed; can be used as a tool for a coding compliance review.

Best choice to aggregate data

Classifications

External cause injury codes

Classifies environmental events, circumstances & conditions as the cause (how an injury happened) of injury, poisoning & other adverse effects.

Data content standards

Clear guidelines & standards for the acceptable values of specified data fields that provide clear descriptors of data elements to be included in an EHR system.

RxNorm

Clinical drug nomenclature & semantic interoperability tool used for cross-mapping, and to facilitate clinical decision support that normalizes generic & brand drug names & attaches a unique identifier to that name.

Administrative data

Coded information contained in secondary records (billing) describing patient identification, diagnosis, procedures, insurance, patient registration information & patient account information.

Acute care hospitals

Collect the standardized HEDIS data elements

HCPCS

Collection of codes & descriptors used to represent healthcare procedures, supplies, products & services.

Utilization management (UM)

Collection of systems & processes to ensure that facilities and resources, both human and nonhuman, are used and are consistent with patient care needs; Program that evaluates the healthcare facility's efficiency in providing necessary care to patients.

Check sheet

Collection tool used to gather data based on sample observation in order to detect patterns.

Systematized Nomenclature of Medicine Clinical Terminology (SNOMED-CT)

Comprehensive clinical terminology that provides clinical content & expressivity for clinical documentation & reporting whose purpose is to standardize clinical phrases, making it easier to produce accurate EHR information.

Access control

Computer software program designed to prevent unauthorized use of PHI; technical safeguard and restriction of access to information to only those who are authorized by role or other means.

Minimum necessary

Concept that the HIPAA Privacy Rule requires that CE's must limit use, access, & disclosure of PHI to only the amount needed to accomplish the intended purpose.

Main components of SNOMED CT

Concepts, descriptions & relationships

Comorbid Condition

Condition that existed at admission & will likely cause an increase in the patient's LOS.

Retrospective utilization review

Conducted after a patinet is discharged & done prior to an administrative utilizaiton review that examines the medical necessity of the services provided to the patient while in the hospital.

Healthcare Cost and Utilization Project (HCUP)

Consists of a set of databases that are unique because they include data on inpatient whose care is paid for by all types of payers, including Medicare, Medicaid, private insurance, self-paying, & uninsured patients.

Workforce members

Consists of employees, volunteers, student interns, trainees, employees of outsourced vendors whose conduct, in the performance of work for a CE or BA & routinely work on-site in a CE's facility.

Derived data

Consists of factual details aggregated or summarized from a group of health records that provide no means of identifying specific patients; these data should have the same level of confidentialtiy as the LHR.

When a patient notices an unknown item in the EOB that they do not recognize the service being paid for, the patient should:

Contact the insurer and the provider who billed for the services to correct the information.

Continuity of Care Record (CCR)

Core data set of the most relevant administrative, demographic, & clinical information about a patient's healthcare, that provides a means for 1 healthcare provider system or setting to aggregate all of the pertinent data about a patient & forward it to another provider, system or setting.

Root operation revision

Correcting, to the extent possible a portion of a malfunctioning device or the position of a displaced device.

Medical necessity review

Cost control method to evalaute the need for & the intensity of the service prior to it being provided. Services that are cosmetic, elective & investigational are much less likely to be considered.

Unit labor cost

Cost determined by dividing the total annual compensation by total annual productivity.

Example of what a coding audit should do when discovering unbundling coding:

Counsel the coder & stop the practice immediately.

Data normalization

Critical process of brining data into a commom format that allows for collaborative research, a large scale analytics, and sharing of sophisticated tools.

Participants in coding compliance education

Current or newly hired coding personnel & medical staff.

Quality improvement organizations (QIOs)

Currently under contract with CMS to perform a Hospital payment monitoring program, which targets specfic DRGs and discharges that have been identified as @ high-risk for payment errors that are identified using PEPPER.

Root operation division

Cutting into a body part without drawing fluids and/or gases from the body part in order to separate or transect a body part.

Root operation excision

Cutting out or off, without replacement, a portion of a body part.

Root operation resection

Cutting out or off, without replacement, all of a body part.

Example of aggregate data

Data about all patients who suffered an acute myocardial infarction during a specific time period could be collected in a database.

Prescriptive analytics

Data analytics technique that tries to determine the best solution or outcome among various choices.

Data Quality Dimensions

Data availability, consistency & defintion

Secondary data

Data derived from the primary patient record such as an index, registry or database for things such as research & quality patient safety.

Aggregate data

Data extracted from individual health records and combined to form de-identified information about groups of patients that can be compared and analyzed.

Normal distribution

Data follows a symmetrical curve where the mean, median and mode are equal.

MEDPAR

Data for all Medicare claims for acute care hospital & SNF; Used to research topics related to types of care & DRGs, but only for Medicare patients.

Comparative data collection

Data found on sites such as Hospital Compare use aggregated data to describe the experience of unique types of patinets with one or more aspects of their care.

The evaluation of coders is recommended at least quarterly for the purpose of measurement and assurance of:

Data quality and integrity

Characteristics of high-quality healthcare data

Data relevancy, currency & accountability

UHDDS

Data set that ensures the system collects all federally required discharge data elements that include patient-specticic items on every patient for Medicare & Mediciad inpatients in an acute-care hospital.

DEEDS

Data set whose purpose is to support the uniform collection of data in hospital-based emergency departments and to reduce incompatibilities in emergency department records; most helpful in developing a hospital trauma registry.

Data precision

Data should be precise & collected in its exact form within the course of patient care. Example: height.

Structured data

Data that are readable and intepreted by a computer.

Real-time analysis

Data that can be accessed as it comes into a computer system.

Information

Data that have been filtered & processed into a usable form & put into context.

Discrete data

Data that represent separate and distinct values and observations; that is data that contain only finite numbers and have only specified values.

Post-acute-care transfer (PACT)

Dependent on the reported dicharge disposition for the admission; exceptions includes inpatient rehab, long-term care, psychiatric, childrens or cancer hosptials.

Healthcare Effectiveness Data & Information Set (HEDIS)

Designed to collect administrative, claims, & health record review data in order to evaluate & compare the success of various treatment plans; survey vendors, clinics & hospitals and compare the performance of MCO plans.

Primary diagnosis in the IPPS

Determines the MDC assignment that is deteremined by the appropriate MS-DRG (classified into 1 or 25 MDC's).

Compliance with OIG guidleines

Develop, implement and monitor written policies and procedures.

American Psychiatric Association (APA)

Developed the Diagnostic & Statistical Manual of Mental Disorders (DSM)

Corrective action plan

Devised to respond to issues arising from the CDI compliance & operational audit process.

Range

Distance or extent between possible extremes that is calculated by subtracting the lowest value from the highest value.

Competency

Do statements identifying measurable skills, abilities, behaviors or other characteristics required of an individual in order to complete the work required in a successful manner.

Primary purposes of the health record

Document patient care delivery, management of patient care, administrative purposes.

Demand letter

Document sent to the provider notifying them of RAC determination which includes the providers identification, reason for review, list of claims, reasons for any denials & amoung of the overpayment for each claim.

Subpoena duces tecum

Document that directs an individual to bring originals or copies of records to court.

Contingency plan

Documentation of the process for recording to a system emergency (performance of backups, line-up of critical alternative facilities); a recovery plan in the event of a power failure, disaster or other emergency that limits or eliminates access to facilitates & protected e-PHI; an administrative safeguard.

Consultation report function

Documents opinions about the patient's condition from the perspective of a physician not previously involved in the patient's case.

Dairy method

Documents performance data and tasks for a period of time on how the department spends their time.

Consultation report

Documents the clinical opinion of a physican other than the primary or attending physician and is based on the consulting physician's exam of the patients & a review of their health record's findings, impressions & recommendations.

Chief Complaint (CC)

Documents the nature and duration of the symptoms that caused a patient to seek medical attention as stated in the patients own words.

Example of an early adopter step in the innovvation adoption life cycle:

Dr. Jones is the first physician in the practice to adopt the e-prescribing application. He says he likes to try out new technologies & be a role model for other physicians.n

Secondary purposes of the health record

Education of healthcare professionals, legal, accreditation, policy development, and public health & research activities.

The JC must review its formulary annually to ensure a medication's continued:

Efficacy and safety

Electronic point-of-care charting

Electronic systems used by nurses and physicians to document assessments and findings.

Validity

Element of coding quality that represent the degree to which codes accurately reflect the patient's diagnoses & procedures.

Overall goal of documentation standards

Ensure what is documented in the health record is complete and accurately reflects the treatment provided to the patient.

Primary key in a databse

Ensures that each row in a table is unique, must not change in value. Typically is a number that is one up counter or a randomly generated number independent of the data in a table.

Identify management

Ensures that the individual who has been identified is who they say they are that they have the authority to do what they want to do, and that their actions are tracked.

Focus areas of claims auditing

Ensuring claims are not submitted more than once, ensuring documentaiton supports services reported on the claim and making sure procedures are reported @ the appropriate level.

Data accessibility example

Ensuring that the nurse has access to the health record of patients that their treating.

Consistency

Ensuring the patient data is reliable and the same across the entire patient encounter; the pateint data within the record should be the same and should not contradict other data in the patient record.

Any surgical procedure documentaiton requirement:

Entire process if recorded with an anestehsia report, operative report and recovery room report.

Public Law 89-97 of 1965

Federal law that created Medicare & Mediciad

Straight numeric

Filed based directly by the record number in numeric order.

Terminal digit filing

Filed by the last two digitis (terminal digists) then the middle two (secondary unit) then the first two (teritary units).

Alphanumeric filing system

Filled by the first two letters of patinets last name followed by a unique numeric identifer. Example: SA1234

Common network safeguards

Firewalls (secure gateway) Cryptographic technologies (encryption, digital signatures & certificates) Web Security protocols (TLS & SSL) manual intrusion detection (log files, audit trails) & Intrusion Detection Systems (IDS).

Risk manager's principal tool

For capturing the facts about PCE's; carefully structure the collection of data, information, and facts in a relatively simple format.

Change management

Formal process of introducing change, getting it adopted, and diffusing it throughout the organization.

Categorgical data

Four types of data (nominal, ordinal, interval & ratio) that represent values or observations that can be sorted into a category.

Controlling

Function in which performance is monitored according to policies and procedures that includes monitoring the performance of employees for quality, accuracy, & timeliness of completion of duties. (Ex: In HIM prearing a dashboard report with KPIs).

SI's in the APC payment category

G (pass through drugs and biologicals) K (non-pass) R (blood/products) S (significant procedures for which mutliple procedures reduction does not apply) T (surgical procedures for which multiple procedure reduction applies, U (brachterhapy services) and V (clinic & emergency department visits).

Conditions of Participation

General name for Medicare rules that provide administrative & operational guidelines & regulations under which facilities are allowed to take part in the Medicare & Medicaid programs, published by CMS which affects healthcare organizations.

Emancipated minors

Generally may authorize the access and disclosure of their own PHI. If the minor is married or previously married the minor may authorize the disclosure or use of thier information, if the minor is under the age of 18 and is the parent of a chile, the minor may authorize the access and disclosure of their information and thier child's.

Complex wound repair

Goes beyond layer closure of a laceration that requires scar revision, debridement, extensive undermining stents or retention sutures.

Federal rules of evidence

Governs admissibility in the federal court system.

User-based access control (UBAC)

Grants access based on a user's individual identity

Line graph

Graphic technique that shows continuous data and trends over time.

Bar graph/chart

Graphic technique used to display frequency distributions of nominal or ordinal data that fall into categories.

Histogram

Graphic technique used to display the frequency distribution of continuous numerical data (interval or ratio data) as either numbers or percentages in a series of bars.

Graph

Graphic tool used to show numerical data in a pictorial representation.

National Health Information Network

Group of federal agenceis and no-federal organizations that came together under a common mission & purpose to improve patient care, streamline disability benefit claims and improve public health reporting through secure, trusted, and interoperable HIE.

Hospital aquired conditions (HACs)

Group of reasonably preventable conditions for which hospitals should not receive additional payment when one of the conditions was not present on admisison.

Designated Record Set (DRS)

Group of records maintained by or for a CE that includes health records, billing records, various claim records that are used to make decisions about an individual; HIPAA provisions apply to this.

Requesting access to PHI

HIPAA gives the right to request access to their PHI, but the CE may require it be in writing & must be acted on no later than 30 days after the request that may have an extension of 30 more days & 60 days for off-site PHI.

Qualifications of Critical Access Hospitals

Has to be located in a rural area,

Reliable statiscal data must:

Have some consistency.

Compliance concern for MS-DRG's

Health record documentation used to support the coding of principal diagnosis, complications and comorbidites may not always be clear or used appropriately by the coder (such as undercoding) causing inappropriate reimbursement that affects a hospitals' case mix.

Institutional users of the health record

Healthcare delivery organizations, third party payers, medical review organizations, research organizations, accreditation organizations, government licensing agencies, & policy making bodies.

Automatic controls of electronic systems

Helps preserve data confidentiality & integirty by edit checks, audit trails & password managment.

Benefits of claim submission coding comparison

Helps to identify whether the communicaiton software between the health record system & billing system is functioning correctly & could find claim generation issues that cannot be found other ways.

Disclosure

How health information is disseminated outside (externally) an organization.

Most constant threat to health information integrity

Human threats

Monitoring programs for inpatients should regulary audit:

ICD-10-CM and ICD-10-PCS coding

Access safeguards

Identification of which employees should have access to what data. (General practice: Employees should have access ONLY to data they need to do their respective jobs).

Ad hoc or demand report example

Identifies all medical staff members who have suspended in the past 6 weeks due to delinquent health records.

NCCI editor function

Identifies procedures & services that cannot be billed together on the same day of service for a patient.

Auditing process

Identifies risk areas such as chargemaster description, medical ncessity, MS-DRG coding accuracy, variations in case mix etc.

HIM professionals role in medical identity theft protection programs:

Identify resources to assist patients who are victims of medical identity theft, ensure safeguards are in place to protect the privacy and security of PHI, and balance patient privacy proteciton with disclosing medical idnentity theft to victims.

Operative report example

Identify where the following the information would be found in the acute-care record: "Following induction of an adequate general anesthesia, and with the patient supine on the padded table, the left upper extremity was prepped and draped in the standard fashion."

HCUP data elements

Include demographic information, information on diagnoses & procedures, admission & discharge status, payment sources, total charges, LOS, and information on the hospital or feeestanding ambulaotry surgery center.

Near miss

Include occurrences that do non necessariy affect an outcome but if they were to recur, they would carry significant chance of being a serious adverse event.

Utilization controls

Include prospective and retrospective review of the healthcare services planned for or provided to patients.

QIO's responsibilities

Include reviewing health records to confrim the validity of hospital diagnsosis and procedure coding data completeness.

Secondary purposes

Include support for public health and research

Instiutional users of the health record

Include's healthcare delivery organizations, third-party payers, medical review, research, educational, and accreditation organizations, government licensing agencies and policy-making bodies.

New employee orientation

Includes a group of activites to help the employee feel knowledgeable and competent; educational programs required for employees organizationalwide are trained.

Discharged not final billed (DNFB)

Includes accounts that have been discharged & have not been billed for a variety of reasons.

Medication Administration Record (MAR)

Includes clinical lab reports should be reviewed to determine if a partial thromboplastin time (PTT) test was performed which should be reviewed to determine if heparin was given after the PTT test was performed.

Examples of external security threats

Includes natural disasters such a earthquakes, tornadoes, floods, and hurricanes that can demolish physical facilities and electrical utilities.

Patient registration

Includes patients full name, medical record number, add, phone number, DOB, gender, marital status, next of kin, optional information is religious affiliation, race, AD or private or confidential patient.

Staffing tools

Includes position descriptions, which outline the work & qualifications required by the job; performance standards, which establish expectations for how well the job will be done & how much work will be accomplished & written policies and procedures explaining staffing requirements & scheduling used to plan and manage staff resources.

High-risk billing practices

Includes, billing for noncovered services, altered claim forsm, duplicate billing, misrepresenttion of facts on a claim form, failing to return overpayments, unbundling, billing for medically unnecessary services, overcoding & upcoding, billing for items or services not rendered & false cost reports that represent a major compliance risk for healthcare organizations.

Federal Rules of Civil Procedure (FRCP)

Incorporated electronic information through the creation of e-discovery rules that apply only to cases in federal district courts.

Receipt of Breach Notice

Indicates that the patient's PHI was involved in a data breach.

Release of Information (ROI)

Information system that is a process of providing PHI access to individuals or facilities that are deemed to be authorized to either receive or review.

Clinical data

Information that reflect the treatment & services provided to the patient & how the patient responded to the treatment that is the largest portion of the health record.

Difference between hospital inpatient and a hospital outpatient

Inpatients receive room, board and continuous nursing services in areas of the hospital where patients generally stay overnight; whereas, outpatients receive ambulatory diagnostic and therapeutic services.

Willful neglect

Intentionallly failing to comply with HIPAA provisoins.

Internal Classification of Diseases for Oncology 3rd Edition (ICD-O-3)

Is a derived classification system based on ICD & reference classification that classifies the topography & morphology of neoplasms codes.

Structured data example

Is a diagnosis code in the proper format within the system such as an ICD-10-CM code format XXX.XXXX.

Procedure

Is a document that describes the steps involved in performing a specific function that deine the processes by which the policies are put into action.

Computer-based training method

Is a form of self-directed learning, an approach that allows learners to control their own education at their own pace (flexibility).

Planned change

Is a formal process that is introduced methodically & is actively influenced by manager or change agents.

Access controls

Is a fundamental security strategy, being able to identify which employees should have access to what data; general practice is that employees should have access only to data they need to do their jobs.

EMPI

Is a list or databse created or maintained by a healthcare faiclity ro record the name and identification number

Accession number

Is a number assigned to each case as it is entered into a cancer registry.

Needs analysis

Is a procedure performed by collecting & analyzing data to determine what is required, lacking or desired by an employee group or organization.

Performs a needs assessment

Is a process for determining how to close a learning or performance gap as it relates to jobs performed in a particular department.

AHIMA foundation

Is a separately incorporated philanthropic & charitable arm of AHIMA that promotes education & research in health information management.

Utilization mangement

Is a set of processes used to determine the appropriateness of medical services provided during specific episodes or care.

Delegation

Is a skill that managers develop to show employees that they trust them with authority to perform certain projects on their own that falls under the organzing managerial function.

Work sampling

Is a statistical method that reviews a select portion of tasks performed & provides baseline data for further job performance assessment; takes into account the quantity of activities that can be completed within a certain timeframe.

Vulnerability

Is a weakness or gap in security protection.

Advance directive

Is a written document that provides directions about a patient's desires in relation of care decisions for use by health care workers if the patient is incapaciated or not capable of communication.

Delinquent record

Is an incomplete record that is not recetified within a specific number of days as indicated in the medical staff and regulations.

Cause-and-effect diagram

Is an investigational technique that facilitates the identification of the various factors that contribute to a problem.

Breach

Is an unauthorized acquisition, access, use or disclosure of PHI that compromises the secruity or privacy of such information (has some exceptions).

POI indicator

Is assigned to principal & secondary diagnoses & the external cause of injury codes based on physician documentation.

Performance Improvement (PI)

Is based on serveral fundamental principles, including the structure of a system determines its performance, all systems demonstrate variation, improvments rely on the collection & analysis of data that increase knowledge.

Accuracy of coding

Is best determined by a predefined audit process, the audit allows the facility to confirm that the policies and procedures are being met and to identify problems that need to be addressed and corrected.

Problem-oriented health record

Is better suited to serve the patient and the end user of the patient's information. The key characteristics of this format is an itemized list of the patient's past & present social, psychological and health problems.

Vital signs record

Is comprised of blood pressure readings, temperature, respirations and pulse, making it the best source to gather this type of information.

Organization

Is coordinating all of the tasks and responsibilities of a department to guarantee the work to be accomplished is complete correctly.

Real-time data

Is easily assessable format like a dashboard and allows a leader to keep track of high-impact, high-risk, or high-value processes and make adjustemnts on a daily basis if needed.

Calculat total number of inpatient service days

Is equal to the daily inpatient census counting one service day for each paitnet treated

Utilization manager's role

Is essential to prevent denials for inappropriate levels of service.

Front-end utilization management (UM)

Is essential to the prevention of denials for inappropriate levels of care,

Corporate Integrity Agreement (CIA)

Is essentially a compliance program imposed by the government, with substantial goverment oversight and outside expert invovlemen in the organization's compliance activites. The OIG imposes this on providers when fraud and abuse is discovered through an investigation.

Controlled vocabulary

Is necessary to ensure that each term used in an EHR has a common meaning to all users.

Security awareness program

Is not an automatic control that helps preserve data confidentiality & integrity in an electronic system.

HIM Director or supervisor

Is responsible for the decisions concerning the division of labor for the HIM department.

Strategic plan

Is the document in which the leadership of a healthcare organization identifies the organization's overall mission, vision and goals to help define the long-term direction of the organization.

Planning managerial function

Is the examination of the future & preparation of action strategies to attain goals of the department or healthcare facility. (Ex: Performing an envrionmental scan of internal organization & external industry).

Leading

Is the function in which people are directed & motivated to achieve the goals of the healthcare organization. (Ex: HIM direcotr asking all department personnel to report to the emergency staging area to help with record management).

Standard deviation

Is the measure of variablity that is used most often and displays how data are related to the mean.

Medican for even numbers

Is the midpoint between two middle observations, found by averaging the 2 middle scores (formula is x + y/2).

Data recovery

Is the process of recoupig lost data or reconciling conflicting data after the system fails, these data may be from events that occurred while the system was down or from backed-up data.

Diversion

Is the removal of medication from its usual stream of preparation, dispensing and administration by personnel invovled in those steps in order to use or sell the medication in non-healthcare settings.

Drug diversion

Is the removal of medication from its usual stream of prepartion, dispensing, and administration by personnel invovled in those steps in order to use or sell the medication in non-healthcare settings.

Operational plan

Is the specfic day to day tasks required in operating a healthcare organization or an HIM department. Making up the weekly work schedule is part of this funciton.

Turnaround time

Is the time between receipt of the ROI request & when the request is sent to the requestor.

Asymptomatic HIV infection status code

Is to be used when the patient without any documentation of symptoms is listed as being positive or having known HIV.

Most important to DG and IG programs

Is to decrease security breaches.

Goal of quantiative analysis

Is to make sure there are no missing reports, forms or required signatures in a patient record and identify deficiences early so they can be corrected.

Goal of CDI compliance review

Is to monitor compliant query generation and physical responses.

Major purposes of the LHR

Is to serve as teh legal business record of an organization and as evidence in lawsuits or legal actions and such it would be the record released upon a valid request.

EHR risk analysis

Is useful to identify security threats

Health record risk analysis

Is useful to identify security threats.

Record over record method advantages & disadvantages

It allows for benchmarking with other hospitals that frequently use it, permits reviewers to track errors by case type & enables them to relate productivity with quality errors on a case by case basis, much quicker to calculate, it lacks specificity because it does not identify the coder's ability to assign codes & the number of secondary diagnosis or procedures missed by the coder.

Example of a security vulnerability

Lack of laptop encryption.

Confidentiality

Legal term used to define the protection of health information in a patient-provider relationship.

Privacy

Legal term used to describe when a patient has the right to control disclosure of PHI from being disclosed to anyone.

X placeholder

Letter character used to represent certain codes to allow for future expansion of the classification system.

Risk determination considers the factors of:

Likelihood & impact

Context-based access control (CBAC)

Limits a user's access based not only on identity & role but also a person's location & time of access.

Forward map in data mapping

Linking an older version of a code set to a newer version.

Diagnosis-related groups (DRGs) are organized into:

Major diagnostic categories (MDCs)

AHIMA engage

Make up a virtual network for AHIMA members who communicate via a web-based program managed by AHIMA.

Comprehensive Error Rate Testing (CERT) program

Measures improper payments in various healthcare settings for Medicare.

Types of software application safeguards

Mechanisms (passwords, tokens or biometrics) Audit trails, and edit checks.

Comorbidity

Medical condition that coexists with the primary cause of the hospitalization and affects the patient's treatment and LOS.

Credentialing and privileging process must be defined in:

Medical staff bylaws

Case finding

Method used to identify the patients who have been seen or treated in the facility for the particular disease or condition of interest to the registry.

Jacket microfilm

Microfilm is cut and inserted into 4X6 inch jackets with sleeves.

Main goal of hospice patient treatment

Minimize the stress and trauma of death.

Good electronic forms design

Minimizes keystrokes by using pop-up menus, performs completeness check for all required data & uses text boxes to enter text.

Data accuracy example

Monitoring the chart in the analysis of patient notes in the PHR to ensure they support the diagnosis throughout the entire health record.

Query

Most common CDI tool used for communication with providers to obtain clinical clarification with providers, documentation alerts, clarify documentation or ask additional questions in regards to documentation.

Unit numbering system

Most common system that issues a health record number at a first encounter which is then used for all subsequent encounters.

Front-end speech recognition

Occurs when physicians review and edit the document directly upon dictation and then are able to sign it immediately.

Federal Sentencing Guidelines

Outlines seven steps as the hallmark of an effective program to prevent & detect violations of law. These seven steps were the basis for the OIG's recommendations that made the adoption of an effective corporate complinace program common.

Data timeliness

Patient documentation should be entered promptly ensuring up to date information is available within specified & required time frames.

Components of a meaningful consent program

Patient education and engagement, technology and law & policy.

Formula for determining how many FTE's are needed:

Patient encounters divided by productivity.

Typical data fields used for the purpose of finding:

Patient name, zip code, health record number, patient account number, attending physician exc.

Physician orders for DNR should be consitent with:

Patient's advance directive.

Example of the definition of the term data:

Patient's laboratory value is 50.

Medicare severity diagnosis-related groups (MS-DRGs)

Payment groups designed for the Medicare populaton that recognize the severity of illness, resources use, & patient complexity.

Middle managers

People within the organization who oversee the operation of a broad scope of functions such as coding, transcription, and ROI @ the department level.

Principle of contemporary PI

Performance improvement (PI) relies on the collection and analysis of data to increase knowledge.

Automated review

Performed electronically by a software program that analyzes claims data to identify improper payments rather than by humans.

Root operation destruction

Physical eradication of all or a portion of a body part by the direct use of energy, force or a destructive agent.

Example of a secondary data source

Physician index

Heat map

Plots all data points as a cell for two given variables or interest and depending on the frequency of observations in each cell, provides color to visualize high and low frequency.

Organizational tools

Policies and procedures spell out what the organization expects employees to do and how they are expectec to do it.

EHR version control

Policies and procedures to control which versions is displayed.

Risk of copy and paste documentation in the EHR

Practice is dangerous as inaccurate information easily be copied such as copying a note in the wrong patient's record; propagation of false information in the record.

Upcoding

Practice of assigning diagnostic or procedural codes that represent higher payment rates than the actually services provided.

Unbundling

Practice of assigning multiple (separate) codes rather than using an available single comprehensive code.

Policies

Principles describing how an organization will handle a specific situation or evaluate a specific process; clear simple comprehensive statements that establishes the parameters for decision making & action and is written description of the organization's formal position; developed at both the institutional and departmental levels in accordance with applicable laws that reflect actual practice.

Commission on Accreditation of Rehabilitation Facilities (CARF)

Private, not-for-profit organization committed to developing & maintaining practical, customer-focused standards to help organizations measure & improve the quality, value & outcomes of behavioral health & medical rehabilitation programs.

Risk management

Process followed to mitigate and fix issues that arise during a review of systems that contains PHI to reduce vulnerabilities; encompasses the identification, evaluation and control of risks that are inherent in unexpected and inappropriate events.

Data warehousing

Process of collecting data from sources within an organization for decision making purposes; single database that helps locate data that exists in multiple databases.

Release of information (ROI)

Process of disclosing patient information from the medical record to another party. Federal, state, and local regulations exist to govern this function.

Reconciliation

Process of ensuring that a record is available for every patient seen at the healthcare facility.

Compliance

Process of establishing an organizational culture that promotes the prevention, detection & resolution of instances of conduct that do not conform to federal, state or private payer healthcare program requirements or the heatlhcare organization's ethical & business policies.

Data mining

Process of extracting & analyzing large volumes of information from a database then quantifying and filtering discrete, structured data used by companies to turn raw data into useful information.

Abstracting or indexing

Process of extracting elements of data from a source document or database and entering them into an automated system; the purpose is to make the data elements avilable for later use; after a data element is catpured in electronic form it is aggregated into a group of data elements to provide information needed by the user.

Authentication

Process of identifying the source of health record entries by attaching a handwritten or electronic signature,or author's; proof of authorship that ensures that log-ins & messages from a user originate from an authorized source.

Data capture

Process of recording healthcare-related data in a health record system or clinical database.

Purgining records

Process of removing health records and sending them to the storage facility.

Cost-control process for inpatient surgical services:

Prospectively precertify the necessity of inpatient services.

Detailed query documentation can be used to:

Protect the hospital against claims from physicians about leading queries.

Data security's basic concepts

Protecting the prviacy of data, ensuring the integrity of data, ensuring the availability of data.

HIPAA Privacy Rule's key goals

Provide a greater privacy protections of PHI & to provide greater rights with respect to an individuals health information.

Health records role as a legal document

Provide critical evidence in the legal process including personal injury lawsuits, criminal cases, healthcare fraud & abuse investigations & actions and quasi-judicial workers compensation determinations.

Basic elements of a coding compliance program

Provide ongoing training to all coding staff, implement comprehensive policies & procedures, examine the quality of coding through audits, ensure that coding practices follow offical coding guidelines, support codes with health record documentation, use best practices to write a query, disseminate memorandums, verify advise of consultants, monitor changes in regulations, compare facility metrics, monitor claims denials, review data to identify any significant changes, ensure the person maintaining the chargemaster is knowledgeable and report any possible fraud to the facility's compliance officer.

Health record owner

Provider who generated the information.

National Practitioner Data Bank (NPDB)

Provides a database of medical malpractice payments, adverse licensure actions and certain professional review actions taken by healthcare entities.

Clinical Documentation Improvement (CDI) program

Provides a mechanism for coding staff to communicate with the physician regarding nonspecific diagnostic statements or when additioanl diagnoses are suspected but no clearly stated which facilitates accurate coding & helps coders to avoid assumption coding.

OIG Workplan

Provides information on new and ongoing reviews or audits each year.

Clinical Support Services

Provides pharmaceutical services, food, nutrition services, social work services, and patient advocacy services.

Root operation insertion

Putting in a nonbiological appliance that nomitors, assists, performs, or prevents a physiological function but does not physically take the place of the body part.

Root operation transplantation

Putting in or on all or a portion of a living body part taken from another individual or animal to physically take the place and/or function of all or a portion of a similar body part.

Root operation supplement

Putting in or on biological or syntehtic material that physically reinforces and/or augments the function of a portion of a body part.

Root operation replacement

Putting in or on biologifal or synthetic material that physically takes the place and/or funciton of all or a portion of a body part.

Net autopsy rate

Ratio of inpatient autopsies compared to inpatient deaths calculated by dividing the total number of inpatient autopsies perfromed by the hosptial patholgist for a given period by the total number of inpatinet deaths minus unautopsied cornoer's or medical examiners' cases for the same time period.

Pharmacy information system

Receives orders for drugs that aids in chekcing for contradications (such as allergies), directs staff in compounding any drugs requrigin special prepartion, & aids in dispensing the drug in the appropriate dose and route of administration.

Source oriented health record

Record organized by source. Example: All nursing notes together.

Sampling

Recording of a smaller subset of observations of the characteristics or parameter, making certain, however, that a sufficient number of observations have been made to predict the overall configuration of the data.

Audit trails

Recording of activites occurring in an information system, can monitor system level controls such as login, logout, unsuccessful logins, print, query and other actions such as user-identificaiton information and the date and time of the activity; are required by HIPAA.

Cancer registry

Records maintained by many states for the purpose of tracking the incidence (new cases) of cancer that is considered a secondary data source.

Primary purpose of structured data entry

Reduce documentation variability

Information assets

Refer to the information collected during day to day operations that is considered to add value to an organiztion.

Physical safeguards

Refer to the physical protection of information resources from physical damage, loss from natural or other disasters, and theft, includes protection & monitoring of the workplace, computing facilities, and any type of hardware or supporting information system infrasturcutre such as wiring closets, cables, and telephone and data lines, using doors, locks, audible alarms, and cameras should be installed to protect particulary sensitive areas such a s data centers.

Mortality

Referring to the incidence of death in a specific population; loss of subjects during the course of clinical reasech studies.

Morbidity

Referring to the state of being diseased (including illness, injury or deviation from normal health) the number of sick persons or cases of disease in relationship to a specific population.

Record authentication

Refers to establishment of its baseline trustworthiness.

Classroom-based learning

Refers to instructor led, face to face training such as traditional lectures, workshops & seminars; method is commonly used by managers because it is familiar and content is relatively quick, easy & inexpensive to develop.

Device and media controls

Require the facility to specify proper use of electronic media and devices (external drives, backup devices, etc.) Controls and procedures regarding the receipt and removal of electronic media that contain protected health information and the movement of such data within the facility.

Public Law 92-603 of 1972

Required concurrent review for Medicare & Mediciad patients

Breach Notificaiton Rule

Requires CE's to notify affected individuals when a breach occurs

Breach notification requirements

Requires a CE to follow a discovery of unsecured PHI then notify each individual whose unsecured PHI has been or is reasonably believed by the CE to have been, accessed, acquired, used or disclosed.

Access controls standard

Requires implementaiton of technical procedures to control or limit access to health information, the procedures would be executed through some type of software program; ensures taht individuals are given authorization to access only the data they need to perform their respective jobs.

The HIPAA Security Awareness and Training administrative safeguard:

Requires log-in monitoring, password management & security reminders for an entity's workforce.

Safe harbor method of deidentification

Requires the removal of 18 specific identification from th the PHI.

Evidence-based medicine

Research concept of large populations studies that are used to identify the care processes or interventions that achieve the best healthcare outcomes in different types of medical practices.

OIG workplan

Resource that provides information on new and ongoing reviews and audits each year in programs administered by HHS.

The benefits of a coding compliance plan include the following:

Retention of high standard of coding.

Complication

Secondary condition that arises during hospitalization.

Descriptive statistics

Set of statistical techniques used to describe data such as means, frequency distributions, & standard deviations; statistical information that describes the characteristics of a specific group or a population.

When assessing data quality:

Several factors must be addressed which include, data accuracy, consistency, comprehensivensss and timeliness.

Security audit process

Should include triggers that identify the need for a closer inspection.

From an evidentiary standpoint, incident reports:

Should not be placed in a patient's health record.

Record retention

Should only be done in accordance with federal and state law.

Medical staff bylaws

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

Roote operation drainage

Taking or letting out fluids and/or gases from a body part.

Root operation change

Taking out or off a device form a body part and putting back an identical or similar device in or on the same body part without cutting or puncturing the skin or a mucous membrane.

Root operation removal

Taking out or off a device from a body part.

Reasonable diligence

Taking reasonable actions to comply with HIPAA provisions.

ICD-10-PCS Drainage root operation

Taking, or letting out fluids and/or gases from a body part (example is I&D).

Data analysis

Task of transforming, summarizing, or modeling data to allow the user to make meaningful conclusions.

Privacy officer

Tasked with reviewing access logs daily to determine whether all access by hospital employees was appropriate.

Derivation business rule example

The ALOS is the sum of inpatient days for a period divided by the number of discharges for a period.

Coding sequencing of multiple burns

The first sequenced diagnosis is the burn to the highest degree burn.

Physical examination example

The following is documented in an acute-care record: "HEENT: Reveals the tympanic membranes, nares, & pharynx to be clear. No obvious head trauma. CHEST: Good bilateral chest sounds."

When preparing to collect data a team should consider:

The four W questions: Who will collect the data? What data will be collected? Where will the data be collcected? When will the data be collected?

CPT coding guidelines on cancelled procedures with a visual procedure

The intended procedure is still coded but it also must have a modifier of -74 that is approriate for discountinued outpatient procedures after anesthesia administration.

Healthcare fraud

The intential deception or misrepresentation that an inidivudal knows (or should know) to be false, or does not believe to be true, & makes, knowing the deception could result in some unauthorized benefit.

American Academy of Professional Coders (AAPC)

The organization that educates & certifies medical coders to contact to receive the Certified Professional Coder (CPC), CPC-P, CPMA, CPCO,CIC,COC,CRC certifications in coding, medical compliance & medical auditing.

Data governance (DG)

The overall management of the availability, usability, integrity & security of the data employed in an organization or enterprise;EIM function that has the overarching authority for managing an organization's data assets.

Denominator

The part of a fraction below the line signifying division that functions as the divisor of the numerator and in fractions with 1 as the numerator indicates into how many parts the unit is divided.

Centrailized unit filing

The patient encounters are filed in a single location.

When HIM department's chart analysis error rate is high or accuracy rate is too low based on policy:

Then correctie action should be taken to meet the department standards.

Disclosure management system

Tracks the disclosures made throughout the healthcare organization for reporting purposes required by HIPAA.

Reliability data quality component example

Two HIM professionals are abstracting data for the same case for a registry. When their work is checked, discrepancies are found.

Concurrent coding

Type of coding that takes place in the hospital while the patient is still receving care.

Subacute care

Type of facility that is generally governed by long-term care documentation standards that offers patients access to constant nursing care while recovering at home.

Retention policies

Type of health record policy that dictates how long individual health records must remain available for authorized use.

Emergency care

Type of health record that contains information about the means by which the patient arrived at the healthcare setting & documentation of care provided to stabilize the patient.

Trauma registry

Type of registry that maintains a database on patients injured by an external physical force & tracks patients with traumatic injuries from the initial treatment to death.

Inferential statistics

Type of statistics that makes a best guess about a larger group of data by drawing conclusions from a smaller group of data.

PHR example

Type of system that Amanda uses to upload her diet & fitness log from her smartwatch to her record. She also adds information about her previous medical history.

Hospital-Aquired Conditions Reduction (HAC) program

Type of value-based purchasing program that CMS desires to pay for value to promote efficiency in resource use while providing high-quality care.

Logical Observation Identifiers, Names & Codes (LOINC)

Universal code system for tests, measurements & observations whose purpose is to standardize lab & clinical codes for use in clinical care, outcomes management, & research that enable exchange & aggregation of electronic health data from many independent systems.

Red Flag Rule

Used as triggers to alert organizations of potential identity theft.

Copies PHRs are considered part of the LHR when:

Used by the organization to provide treatment

MEDPAR file

Used for research on topics such as charges for particular types of care and MS-DRGs; limitation is that it only contains data on Medicare patients.

Reveiw of an audit trail for an EHR

Used for special analysis software to identify suspicious or abnormal system events or behavior, maintains an event of failure occurred.

Scatter chart/plot/diagram or graph

Used to demonstrate a relationship bewteen two variables.

Root operation inspection

Visually and/or manually exploring a body part.

Medicare Integrity Program

Was established under HIPAA to battle healthcare fraud & abuse that is responsible for payment determinations & audit of cost reports.

Traditional practice emphasis of HIM

Was to ensure complete and accurate health records.

Compliance issues

What CDI programs must keep high-quality reocrds of the query process for:

MS-DRG calculated for the encounter

What Medicare inpatient reimbursement levels are based on that are assigned with the help of a grouper.

Licensure

What healthcare organizations must obtain by government entities (such as the state or county in which they are located) to be legally be able to provide services

Overlap

When a patient has more than one health record number @ different locations within an enterprise.

Type 1 transfer

When a patient is discharged from an acute IPPS hospital on the same day, payment is altered fro the transferring hospital and is based on a per diem rate methodology.

Coding guidance on AIDS AKA HIV codes

When a patient is treated for a complication associated with HIV infection, the B20 code is assigned as the principal diagnosis, followed by the code fro the complication.

Secondary cancer site codes

When a patient later develops another neoplasm that is from a history of the primary site & the treatment is directed at the secondary site then the secondary code is assigned first with a cetagory Z85 code used as an additioanl diagnosis code.

ABN is obtained before a service is provided:

When a physician does not provide a diagnosis to justify the medical necessity of a service, the provider may obtain payment from the patient if a________

Data completeness

When a record has quality criterion of quantitative analysis.

Role-Based Access Control (RBAC)

When a role is identified along with the type of information required to perform it.

Example of a trigger event

When a user looks up another patient who has the same last name.

Example of when a query may not be appropriate:

When acute respiratory failure in a patient whose lab report findings appear not to support this diagnosis.

Benchmark AKA Standard of performance or Best practice

When an organization compares its current performance to its own internal historical data, or uses data from similar external organization across the country.

Abstracted

When information that has been taken from the health reocrds of injured patients and entered into the trauma registry database.

Subcategory codes

When provided must be used, codes must be assigned to the highest level of specificty based on provider documentation.

Custodian records

When records for evidence is involved @ the trial, the records custodian is called to witness by 1 party to testify as the authenticity of a record as evidence & veritfy that it contains information about the individual.

Court order for health records release

When served an individual must comply with it.

Coding guidelines for malgnancies & chemotherapy

When the purpose of the encounter or hospital admission is for radiotherapy or antineoplastic chemotheray, use the Z code as the first listed diagnosis, only exception to when treatment is directed at a malignany.

ICD-10-CM coding guideline for sequencing anemia and malignancy code assignment:

When the reason for the encounter is for anemia but the patient also has a malignancy then sequenc the malignancy first as the principal or first listed diagnosis followed by the approrpriate code for the anemia.

Negatively skewed distribution

When the tail is pulled toward the left side of the curve.

Positively skewed distribution

When the tail is pulled toward the right side of the curve.

When not to code signs & symptoms

When they are integral (related) to the diseases process & when there is a documented primary diagnosis.

Access to information

Within the context of electronic health records, protecting data privacy means defending or safeguarding.

UM staff

Work with physicians to ensure that the requested services meet medical necessity requirements and are provided in the most appropriate setting, when the insurer denies the claim, an appeal may be possible.

How patient registration deaprment assisted by the HIM department:

Works to ensure the quality of the data collcted and to correct duplicate and other issues with the MPI.

Correct errors in the paper record

Writes a single line should be drawn om oml tjrpigj the incorrect entry, the word error should be printed at the top of the entry along with a legal signature or inititals, date, time & discipline of the person making the change.

Procedures

Written documents that describe the steps invovled in performing a specific function that defines the processes put into action.

Explanation of benefits (EOB)

Written eport sent from a healthcare insurer to the policy holder & to the provider that describes the healthcare service, its cost, applicable cost sharing & the amount the healthcare insurer will cover (extent of payments made on a claim).

Job description AKA Position description

Written explanation of a job and the duties it entails and is based on information provided by the job analysis; document outlines the work to be performed by a specfic employee or group of employees with the same responsibilities.

Expressed consent

Written or spoken permission granted by a patient to a healthcare provider that allows the provider to provide care.

Living will

Written statement detailing a person's desires regarding their medical treatment in circumstances in which they are no longer able to express informed consent, especially an advance directive.

Types of POA Indicators

Y=diagnosis was present @ time of inpatient admission, N=diagnosis was not present, U=documentation insufficient to determine if the condition was present on admission or not, & W=Clinically undetermined.

Beneficence example

A HIM professional ensuring that patient information is only released to those who have a legal right to access it.

Ratio

A calculation found by dividing one quantity by another.

Disease registry

A centralized collection of data used to improve the quality of care and measure the effectiveness of a particular aspect of healthcare delivery.

Disambiguated data

A challenge in extracting meaningful data from unstrcutred text. Clinical notes often contain terms that have more than 1 meaning. Example: Cold-a disease or body temperature/Discharge-body fluid or leaving a hospital.

Clinical data warehouse

A collection of data that reflects all aspects of hospital operations that is used for reporting and analysis.

Hybrid record

A combination of paper & electronic records that includes both paper & electronic elements which is most commonly used by healthcare settings as they transition to electronic records.

Common Clinical Data Set

A common set of data types & elements & associated standards for use across several certification criteria.

Allied health professional

A credentialed healthcare worker who is not a physician, nurse, psychologist, or pharmacist (for example, a physical or occupational therapist, dietitian, social worker, or LPN).

Data warehouse

A database that makes it possible to access data from multiple databases and combine the results into a single query and reporting interface.

Data dictionary

A descriptive list of names, definitions, & attributes of data elements to be collected in an information system or database whose purpose is to standardize definitions & ensure consistent use & can manage who enters the data.

Interrogatories

A discovery method used to obtain information from other parties in a lawsuit.

Date of birth (DOB)

A discriminating attribute used to disqualify two or more similar records.

Minimum Data Set (MDS)

A federally mandated standard assessment form that Medicare & Medicaid certified nursing facilities must use to collect demographic and clinical data on nursing home residents; includes screening, clinical & functional status elements used for long-term care.

Acknowledgements

A form that provides a mechanism for the resident to recognize receipt of important information.

Flow chart

A graphic tool that uses standard symbols to visually display detailed information, including time and distance, of the sequential flow of work of an individual or a product as it progresses through a process.

Centers for Disease Control and Prevention (CDC)

A group of federal agencies that oversee health promotion and disease control and prevention activities in the US.

EHR steering committee

A group that engages all the various stakeholders in EHR planning and development, this ensures that the EHR planning is comprehensive and starts the process of introducing change and gaoining buy-in.

World Health Organization (WHO)

A group within the United Nations responsible for human health, including combating the spread of infectious diseases and health issues related to natural disasters.

When defining the Legal health record (LHR)

A healthcare provider organization must assess the legal environment, system limitations, & standards of care.

Example of a potential identity fraud risk

A hospital using the patient's SSN as their patient identifier.

Addendum

A late entry added to a health record to provide additional information in conjunction with a previous entry that should be timely and have the current date & reason for the additional information being added to the health record.

Preemption

A legal doctrine that federal law may supersede state laws when federal & state or local laws contradict each other.

Accession registry

A list of cases in a cancer registry in order in which they were entered.

Physician index

A list of patient & their physicians usually arranged according to the physician code numbers assigned by the healthcare facility.

Case-mix

A method of grouping patients according to a predefined set of characteristics.

Unstructured data example

A narrative discharge summary that does not follow a specific format or use a template.

Assessment Example

A notation for a hypertensive patient in a physician ambulatory care progress note reads: "Blood pressure adequately controlled."In which part of a problem-oriented health record progress note is written."

Example of data granularity

A numerical measurement carried out to the appropriate decimal place.

Data collection tool

A paper or electronic form that contains all of the data elements to be collected in the audit

Security breach of PHI example

A patient requesting a copy of a payment made by her insurance company for a surgery she had the last month, the business office copied to the RA notice the organization received from the insurance company but failed to delete or remove the PHI for 10 other patients listed on the same RA.

Personal health record (PHR)

A patient's own copy of health information documenting the patient's health care history and providing information on continuing patient care; tool that is used to collect, track and share past & current information.

Master Patient Index (MPI)

A patient-identifying directory referencing all patients, that is a link to the patient record or information, facilitates patient identification & assists in maintaining a longitudinal patient record from birth to death that should be permanently retained; important source of a patient health record number.

Covered entities (CE)

A person or organization that must comply with the HIPAA Privacy and Security Rules; includes healthcare providers (hospitals,long-term care, physicians & pharmacies), health plans (insurance companies), and healthcare clearinghouses.

Alert Example

A physician is reviewing lab results on a patient in his office, the EHR screen displays 1 set of results in red with a flashing asterisk & also show the result in 3 times higher than the expected value.

Physician order

A physician's written or verbal instructions to the other caregivers involved in a patient's care that is considered clinical data.

Natioanl Correct Coding Initiative (NCCI)

A predefined set of edits created by Medicare to prevent improper payment when incorrect code combinations are reported; contains 2 types of edits, mutually exclusive edits (consist of code paris that should not be reported together for a number of reasons) & PTPs.

Nomenclature

A recognized system of terms that follows pre-established naming conventions.

Facility-based registries

A registry that incudes only cases from a particular type of healthcare facility, such as a hospital or clinic.

Appeal

A request for reconsideration of denial of coverage for healthcare services or rejection of a claim.

Aspect of the CDI program

A standard should be set that all query opportunities within a CDI program should undergo comprehensive review retrospectively at least once a year.

Outcomes & Assessment Information Set (OASIS-C)

A standardized data set designed to provide the necessary data items to measure both outcomes of home health services & patient risk factors of Medicare beneficiaries who are receiving SNF services from a Medicare-certified home health agency.

AHIMA's Code of Ethics

A statement of ethical principles regarding business practices & professional behavior; requirements for HIM professionals to comply with all laws, regulations, and standards of the HIM practice.

Policy

A statement that descibes general guidelines that direct behavior or direct and constrain decision making in the organization.

Continuum of care

A system that guides & tracks patients over time through a comprehensive array of health services spanning all levels and intensity of care.

Point of care charting

A system whereby information is entered into the health record at the time and location of service.

Data consistency example

A test result & diagnosis should be the same throughout the record.

Electronic document management system (EDMS)

A transition technology used by many hospitals to increase access to health record content.

Frequency polygon

A type of line graph that represents and displays a frequency distribution.

Point of service plans

A type of managed care plan in which enrollees are encouraged to select healthcare providers from a network of providers under contract with the plan but are also allowed to select providers outside the network and pay a larger share of the cost.

Ranked data

A type of ordinal data where the group of observations is first arranged from highest to lowest according to magnitude and then assigned numbers that correspond to each observation's place in the sequence.

Population-based registry

A type of registry that includes information with accepted standards of care geopolitical area, such as state or region.

Bubble chart

A type of scatter plot with circular symbols used to compare three variables, the area of the circle indicates the value of a third variable.

SNOMED CT identifier

A unique, numeric and machine-readable integer assigned to each SNOMED CT component

Bed count day

A unit of measure that denotes the presence of one inpatient bed (either occupied or vacant) set up and staffed for use in one 24-hour period

Productivity standards

A unit or performane defined by management in quantitative standards that allows organization to measure how well the organization converts input into output, or labor into a product or service.

Tax Equity & Fiscal Responsibility Act (TEFRA) of 1982

Act that required extensive changes in the Medicare program, whose purpose was to control the rising cost of providing healthcare services to Medicare beneficiaries.

Reasonable accomodation

Actions taken by an employer to allow a disabled applicant or employee access to work opportunity. Examples might include altering their work schedule, modifying office equipment or software.

General documentation guidelines

Address the uniformity, accuracy, completeness, legibility, authenticity, timeliness, frequency & format of health record entries that applies to all categories of health records; developed by AHIMA.

Example of clinical data

Admitting diagnosis

Deterministic algorithm

Algorithm that requires exact matches in data elements such as the patient name, DOB, and SSN.

Health records in any format

All CE's health records are subject to the HIPAA privacy regulations.

Reporting communicable disease

All states have a health department with a division that is required to track and record communicable diseases; the facility must notify the state publich health department when a patient is diagnosed with a communicable disease.

HIPAA secruity

Allows a CE to adopt security protection measures that are appropriate for its organization as long as they meet the minimum security standards.

Telecommuting AKA Remote or Virtual work

Allows employees to use technology to perform work & link with the organization from home or another out of office location. The organization usually provides a computer and the required software.

Data map process

Allows for connections between 2 systems; 2 different coding systems to show the equivalent codes allows for data initally captured for one purpose to be translated and used for another purpose.

Data mapping

Allows for connections between two systems to initially capture data for 1 purpose to be translated and used for another purpose.

Root operation bypass

Altering the route of passage of the contents of a tubular body part.

Code systems

An accumulation of numeric or alphanumeric representations or codes for exchanging or storing information.

Potentially compensable event (PCE)

An event that may result in financial liability for a healthcare organization, for example an injury accident or medical error.

AHIMA House of Delegates

An important component of the volunteer structure of AHIMA that conducts the official business of the organization & functions as its legislative body whose primary function is to govern the HIM profession.

Commission on Accreditation for Health Informatics & Information Management Education (CAHIM)

An independent accrediting organization whose mission is to serve the public interest by establishing & enforcing quality accreditation standards for health informatics & HIM educational programs.

Commission on Certification for Health Informatics & Information Management (CCHIM)

An independent body within AHIMA that establishes & is responsible for AHIMA's certification exams & maintenance of health informatics & information management professionals.

Data element

An individual fact or measurement that is the smallest unique subset of a database; under HIPAA is the smallest named unit of information in a transaction.

Custodian of health records

An individual within an organization who is responsible for authorization to certify records, supervising inspection & copying of records & testifying regarding the care of the patient.

Nosocomial (Hospital-Acquired) Infections

An infection acquired by a patient while receiving care or services in a healthcare organization.

American Society for Testing and Materials (ASTM)

An international organization whose purpose is to establish standards on materials, products, systems & services.

Incident

An occurrence in a medical facility that is inconsistent with accepted standards of care.

Deemed status

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

Database

An organized collection of data, text, references, or pictures in a standardized format, typically stored in a computer system for multiple applications.

Surgical procedure

Any single, separate, systematic process upon or within the body that can be complete in itself that is performed to restore disunited or deficient parts, remove diseased or injured tissues, extract foreign matter, assist in obstetrical delivery, or aid in diagnosis.

Security threat

Anything that can exploit a security vulnerability.

Supoena ad testificandum

Appear at the time and place to testify as to the authenticity of the health records by confirming that they were compiled in the normal course of business and have not been altered in any way.

Modifiers

Appended to the code to provide more information to alert the payer that a payment change is required.

AHIMA's data quality management model domains

Application (purpose) Collection, Warehousing (used to archive data) & Analysis (how data transforms into meaningful use).

Discounting of procedures

Applies to multiple surgical procedures that have a payment status T indicator & are performed during the same operative session. The full APC rate is paid for the surgical procedures with the highest rate & other surgical procedures performed at the same time are reimbursed at 50% of the APC rate.

Conditions of Participation (CoP)

Apply to a variety of healthcare organizations that participate in the Medicare program; participating organizations receive federal funds from the Medicare program for services provided to patients.

Vocabulary standards

Are a list or collection of clinical words or phrases with their meanings; the set of words used by an individual or group within a particular subject field, to provide consistent descriptions of medical terms for an individual's condition in the health record.

Concepts

Are a specific thought or abstract idea.

CC's & MCCs

Are additional or secondary diagnoses that ordinarily extend the LOS

Types of data are important to monitor:

Are based on the healthcare organization's mission and the scope of care and services provided.

Second and third opinions

Are cost containment measures to prevent unnecessary tests, treatments, health devices or surgical procedures.

Nonexempt employee

Are covered by FLSA overtime provisions; this includes hourly-paid jobs.

Quality standards for coding accuracy should be:

As close to 100 percent as possible.

Example of behavioral question

Asking a candidate to relate behavior from the past to a job situation (for example, describe a situation where you had to deal with a subordinate's chronic tarindess and explain how you handled it).

Serial work division

Assembly line fashion, where tasks or steps are handled separately in sequence by multiple individuals.

Physician champions

Assist in educating medical staff members on documentation needed for accurate billing.

Edit checks

Assist in ensuring data integrity by allowing only reasonable and predetermined values to be entered into the computer.

Data security example

Automatic logoff after inactivity

Example of data security

Automatic logoff after inactivity

Types of physical & administrative safeguards

Backup power sources, intrusion protection, identification procedures, backup & recovery procedures, automatic logouts, policies & procedures, 2 factor authentication, GPS, employee education & training programs.

Work measurment

Based on the assessment of internal data on actual work performed within the organization and the calculation of time it takes to do the work. Employees log what they do and the time spent on tasks in units of work received and processed each day.

Medical necesstiy

Based on the effects of a service for the patient's physicanl needs and quality of life.

Clinical documentation policies & procedures should:

Be created by & specifically for each organization.

Reason the hybrid record is challenging

Because HIM has to manage both the electronic and paper media.

Includes methods of conducting a literature search and peer institutions:

Benchmarking

Example of secondary data by an internal user:

Benchmarking with other facilities.

Predictive modeling

Branch of data mining concerned with the prediction of future probabilities and trends.

Root operation fragmentation

Breacking solid matter in a body part into pieces.

A subpoena duces tecum compels the recipient to:

Bring records to a legal proceeding.

Process of destruction of paper-based health records

Burning, shredding, pulping, and pulverizing are all acceptable methods.

Major ways to organize process work:

By serial work divisions and parallel work divisions.

Coding errors

Can affect MS-DRG assignment, thus impacting the revenue cycle.

Workload statistics

Can assist managers with the tasks of monitoring productivity and provide data regarding resoruces used, such as equipment, personnel, services and supplies.

Data comprehensiveness

Certifies all required data include all required elements that should be collected throughout the health record are documented (are present).

Pareto chart

Chart that can help analyze data about the freqeuncy or casues of problem in a process, show data in terms of arranging it into categories and then ranking each category according to its importance and are useful in QI processes.

Litigation

Civil lawsuit or contest in court.

Components of a risk management plan

Claims managment, risk identification & analysis and loss preventaion and reduction.

International Classification of Functioning, Disability & Health (ICF)

Classification of health & health-related domains that describe body functions & structures, activities & participation whose purpose is to provide a scientific basis, establish a common language, permit comparison of data, & provide a systematic doing scheme.

Classifications

Clinical vocabulary, terminology or nomenclature that lists words or phrases with their meanings.

Coding qualtiy review program focus example

Coding completed by new coders because any new coder should have their coded records reviewed prior to releasing the claim for accuracy & quality review.

Serial-unit number system

Combination of serial & unit numbering systems; the 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.

Clinical forms committee

Committee that usually oversees the development & approval of new forms for the health record.

Query method

Common communication to advocate proper documentation practices & can be made in situations when there is clinical evidence for a higher degreee of specificity or severity.

The NPSG scores organizations on areas that:

Commonly lead to patient injury or other negative outcomes that can be prevented when staff utilize standardized procedures.

Performance standards are used to:

Communicate performance expectations.

AHIMA's mission

Community of professionals providing support to members and strengthening the industry and profession.

External benchmarking

Compares an organization's performance to the performance of other organizations that provide the same type of services and are comparable in terms of patient miz and size.

Gap analysis process

Compares omitted clinical information received from external providers with the needed clinical information to make a correct diagnosis.

Proportion example

Comparison of 6 males & 14 females in a class of 20 students with the data reported as 3/1.

Root operation occlusion

Completely closing an orifice or the lumen of a tublar body part.

Cornerstones of HIM

Confidentiality, privacy and security.

Development of health record destruction policies

Consider applicable federal and state statutes & regulations, accreditation standards, pending or ongoing litigation, storage capabilities and cost.

A record is considered a primary data source when it:

Contains data about a patient that has been documented by the professionals who provided care to the patient.

Behavioral health records

Contains family & caregiver input

HHS Office of Inspector General (OIG)

Continues to issue compliance program guidance for various types of healthcare organizations & posts the documents on how to develop fraud & abuse complinace plans on their website.

Software application safeguard

Controls contained in application software or computer programs to protect the security & integrity of information.

Microfiche

Copy of jacket microfilm and is used to be sent out of the HIM department instead of using the orignial Jacket microfilm.

Digital scanners

Create images of handwritten and printed documents that are then stored in health record databases as electronic files in their EDMS; solves many of the problems associated with traditional paper-based health records and hybrid records.

Structural type of metadata

Created during the process of developing entity-relationship diagrams & dataflow diagrams to evaluate HIM procedures prior to the implementation fo the new EHR.

Meaningful Use (MU)

Criteria with specific objectives & measures that hospitals must meet to demonstrate they are using EHRs that positively affect patient care; regulation that was issued by CMS outlining an incentive program.

Vital statsitcs

Data related to births, deaths, marriages & fetal deaths.

Legal health record (LHR)

Defined by each organization; documentation that supports revenue pursued by payers and will be disclosed upon request that can be used for legal testimony.

Data definition example

Defining DOB as the date the individual was born by month, day and a 4 digit year.

Admission is only for dehydration due to a secondary diagnosis:

Dehydration is sequenced first, followed by the code for the secondary diagnosis.

Health record retention policies

Depend on a number of factors, they must comply with state and federal statues and regulations that vary by state and type of organization; health records should be retained for at least the statute of limiations.

Data governance framework

Describes a real or conceptual structure that organizes a system or concept

Backscanning

Describes the processing of scanning past health records into the information system so there is an existing database of patient information.

Metadata

Descriptive data that describes other data to create a clearer understanding of their meaning.

Coding primary diagnosis

Designated & defined as the condition established after study chiefly responsible for occasioning the admission of the patinet to the hospital for care that should be sequenced first.

Bill hold policy

Dictates a wating period of time between discharge & claim submission (dropping the bill).

Anti-kickback Statute

Dictates that physicians can't receive money or other benefits for referring patients to a healthcare facility.

Best action to address a noncompliance issue

Discuss the issue and the importance of compliance with the chief of surgery.

Pie chart

Display's the parts of a whole in graphic form

Progress notes

Documentation that creates a chronological report of the patient's condition and response to treatment during a hospital stay that is entered by nurses, physicians, therapists & social workers.

Loose reports

Documentation that needs to be filed in the health record.

Social service note example

Documentation that says "Spoke to the attending re: my assessment. Provided adoption & counseling information. Spoke to cPS re: referral Case manager to meet with patient & family."

Data granularity example

Documenting results of a lab test with the appropriate number of decimal points.

Data precision example

Documenting the exact measurement such as height or temperature.

False Claims Act (FCA)

Enforces penalities to those who knowingly submit fraudulent claims to Government for payment.

Progressive penalites

Ensure that the minimum penatly appropriate to the level of offense is applied. (may include oral warning, written warning, serious rule violations that result in immediate dismissal).

Cooperating parties

Establish ICD-10-CM and ICD-10-PCS coding guidlines for inpatient acute-care.

Best approach to manage wrong health record or mislabeled errors in the EHR:

Establish an error management team to receive notice of these instances and correct them.

Hospital Standardization Program's primary goal

Establish minimum quality standards for hospitals

Forms control program includes:

Establishing standards, a number and tracking system, testing and evaluation plan, checking the quality or new forms, systematizing storage, inventory and distribution and establishing a forms database.

Proctosignmoidoscopy

Examining the rectum and sigmoid colon.

Sigmoidoscopy

Examining the rectum, sigmoid colon and may include other portions of the descending colon.

Colonoscopy

Examining the transverse colon.

Notice of Privacy Practices (NPP)

Example of acknowledgement that explains how PHI is used & disclosed, patient's rights that is a CE's legal duty to provide.

Root operation dilation

Expanding the orifice or lumen of a tubular body part.

Health information retention policies

Factors inlcude applicable federal and state statutes & regulations, accreditation standards, operational needs of the organization, type of organization to determine how long health records are to be kept.

Common elements of Healthcare Fraud definitions

False representation of fact, failure to disclose a material face & damage to another that reasonably relied on misrepresentation.

MS-DRG triples, pairs, and singles

First level of detail for analyzing the reason for changes in a hospital's Medicare CMI over time.

Standards

Fixed rules that must be followed.

Best tool for clearly explaining the coding process:

Flow chart.

PI philosophies

Focus on measuring perofrmance in the areas of systems, processes and outcomes.

Root operation release

Freeing a body part from an abnormal physical constraint by cutting or by the use of force.

Legal hold

Generally a court order to preserve a healthcare document if there is concern about destruction that supersedes routine destruction procedures.

Recomended query format

Generally includes the patients name, admission date or date of service, health record & account number, date query initaited, name & contact info of the individual initiating the query & statment of the issue in the form of a question along with clinical indicators specified from the chart.

National Patient Safety Goals (NPSGs)

Goals issued by the Joint Commission to improve patient safety in healthcare organizaitons nationwide.

Integrity

Guarding against improper information modification or destruction.

Prebilling coding audits

HIM good professional practice that is used to protect themselves from RAC focusing on areas like identifying coding & billing errors during RAC audits.

Preliminary training

HIM needed this to be recognized as a profession.

Administrative simplification

HIPAA's attempt to streamline and standardize the healthcare industry's non-uniform, inefficient business practices such as billing & the electronic transmission of data.

Use

How an organization avails itself of health information internally.

Laboratory report example

Identify where the following documentation would be found in the acute-care record; "CBC: WBC 12.0,RBC 4.75, HGB 14.8, HCT 43.3, MCV 93."

Roll microfilm

Images stored on a long roll of film, major problem is that patient encounters can be stored on multiple rolls which can make retrievel difficult.

Assigning CC's & MCC's

Impacts the organization's CMI & must be monitored

Deposition

Important discovery method that is a formal proceeeding when the oral testomonies of parties to a lawsuit (plaintiff & defendent) and other relevant witnesses are obtained.

When an individual requests a copy of their PHI the CE may:

Impose a reasonable cost-based fee.

Example that can be used to justify a policy against using the copy & paste function:

Improves the quality of care.

Controlling function

In HIM it includes montiroing the perfromance of employees for qualtiy, accuracy, & timeliness of completion of duties according to policies and procedures.

MS-DRG Medicare base subdivided:

In one of three possible alternatives; MCC, CC & Non-CC.

Laboratory findings

Includes chemistry, urinalysis,serology, and toxicology.

Diagnosis documented as "probable, suspected, questionable, rule out, or working diagnosis"

Indicate uncertainty and are not coded as if existing, rather a code to the highest degree of certainty fot eh encounter or visit, such as signs, symptoms, abnormal test reuslts or other reasons for the visit.

T status indicator

Indicates that it is a significant procedure and multiple procedure reductions will apply, when only 1 CPT procedure code is used then 100% of the fee-based APC will be paid.

Excludes1 note

Indicates that the conditions listed after it cannot ever be used at the same time as the code above this type of note.

Custodian of records

Individual who has been designated as having responsibility for the care, custody, control and proper safekeeping and disclosure of health records & protecting health information in conjunction with the court system.

Data steward

Individual who serves as a bridge between information technology and business and clinical areas while managing each key area.

Internal uses of secondary data

Individuals located within the healthcare facility (ex: Medical, administrative or management staff) that identify patterns & trends that are helpful in patient care, long-range planning, budgeting & benchmarking with other facilities.

Examples of sentinel event

Infant abduction from the nursery or a foreign body left in a patient from surgery.

Information Assets

Information collected during day-to-day operations of a healthcare organization that has value within an organization

Sensitive information

Information such as genetic, adoptive, drug, alcohol, sexual health, and behavioral information that has struct rules, regulations, and provides an ethical grey area when it comes to releasing & providing records.

Demographic data

Information used to identify an individual, such as name, address, gender, age, and other information linked to a specific person

Steps in medical necessity & utilization review

Initial clinical review, peer clinical review & appeals consideration.

Kickbacks

Intential bribes

All threates are categorized as either

Internal (originate within an organization) and external (origniate outside an organizaiton).

Cause and effect diagram AKA fishbone diagram

Investigation technique that facilitates the identificaiton of the various factors that contribute to a problem; root cause analysis in order to determine the cause of the problem.

Internal analysis

Involves reviewing the inner working of the healthcare organization to determine strengths and weaknesses of the business practice and process.

Public law

Involves the government at any level & its realtionship with individuals and organizations; purpose is to define, regulate & enforce rights.

Generator component

Is a battery that's put in devices that attaches to one or two leads, such as cardiac pacemakers to send small currents through a lead (wire) to stimulate the heartbeat.

System of record (SOR)

Is a data management term for information storage that is the authoratative data source for a data element or piece of information.

Reasons why legal health record distinction is imporant:

It is important to an organization's business and legal processes, is the record that is produced upon request, including legal requests, it becomes important to ensure that it is legally sound & defensible as a valid document in legal situations.

Tracer methodology

Joint Commission survey method that involves an evaluation that follows the hospital experiences of past or current patients.

When only possible, probable, suspected, questionable, rule out or working diagnosis is documented:

Just code the signs, symptoms, abnormal test results or other reasons for the outpatient visit.

CDI metrics

Key indicators used to monitor effectiveness of CDI programs, the most widely used key indicator is the case-mix index (CMI).

Supoena

Legal document that instructions a person or entity to do something; specifically instructs when to appear at an appointed time & place to testify; most important discovery tool initiated on behalf of one of the parties in the case and issued through the court.

Uniform Hospital Discharge Data Set (UHDDS)

Lists & defines a set of common data elements for the purpose of comparing health information from hospitals that is collected by acute, short-term ambulatory care hospitals.

Barcodes

Makes the indexing of scanned health records more efficient because it can enter metadata automatically.

Big data

Massive amounts of information that can be interpreted by analtyics to provide an overview of trends or patterns.

Mean

Measure of central tendencey that is determined by calculating the arithmetic average of the observation in a frequency distribution.

Median

Measure of central tendencey that shows the midpoint of a frequency distribution when the observations have been arranged in order form lowest to highest.

Mode

Measure of central tendency that consists of the most frequent observation in a frequency distribution.

Example of an audit log

Metadata

Work measurement

Method based on assessment of internal data collected on actual work performed within an organiztion and the calculation of time it takes to do the work.

Critical incident method

Method of performance appraisal that includes an ongoing written log of examples of an employee's job related behavior during the appraisal period is used. It offers specific examples for development & is important that a manager documents both positive actions and negative incidents.

Components that are monitored

Misfiles, timeliness of storage and retrieval to calculate filing accuracy and timeliness rates.

Example of a behavior of an early indicator of resistance to change:

Missing planning meetings during a department metting about the new project.

Overlay

Mistakenly assigns another persons health record number to another person.

In a mangement sense, controlling means:

Monitoring performance

Root operation reposition

Moving to its normal location or other suitable location, all or a portion of a body part.

Ethical coding practices

Must be followed with appropriate employee counseling and remediation.

Certified coders

Must demonstrate they they are continuing to maintain their knoledge and skill base to maintain their certification they must complete a designated set of continuing education units.

Licensed beds

Name of the type of beds in a hospital that are defined by those authorized by the state.

Primary data use

Nomenclature that allows for the collection of clinical data at a granular level is needed for clinical decision support.

Unstructured data AKA Free text

Nonbinary, human-readable data entered into the system with no format specified; unable to be interpreted by a computer.

Deficiency slip

Notification when a document or signature is missing that identifies the pertinent document and what needs to be done (dictated, completed, and signed)

Overpayment

Occurs when a facility receives higher reimbursement than the facility deserves. Example: When a facility submits 2 or more claims for the same service.

Medical identity theft

Occurs when a patient uses another person's name & insurance information to receive healthcare benefits.

Work imaging

Occurs when the supervisor gets a snapshot of the current process and then use that data, along with benchmarking data, to establish standards for a position within their department.

Daily inpatinet census

Offical count of inpatients taken at midnight.

Officer of the Inspector General (OIG)

Office in the federal government working to combat fraud, waste & abuse to improve the efficiency of HHS programs.

Quantitative data example

One of the questions on the patient satisfaction survey that is sent to the patient after discharge asks for the number of times the nurses chekced the patient's vital signs in a day.

Surgical operation

One or more surgical procedures performed at one time for one patient via a common approach or for a common purpose.

Independent variable

One that is manipulated by the researcher under study.

Concurrent review

Ongoing review while patient is in facility & screening for medical necessity, appropriateness & timeliness of the delivery of medical care from the time of admission to discharge.

Characteristic of breach notification

Only applies when one person's unsecured PHI is breached.

Standing orders

Orders the medical staff or a physician established as routine care for a specific diagnosis or procedure that must be signed, verified & dated.

The Joint Commission

Organization responsible for accrediting healthcare organizations who determine whether the organization is continually monitoring & improving the quality of care provided. Has instituted continuous improvement & sentinel event monitoring & uses tracer methodology during the survey process.

Outguide

Paper-based health record system to track the location of records removed.

Firewall

Part of a computer system or network that is designed to block unauthorized acess while permitting authorized communication; it's a software program or device that filters information between 2 networks, usually between a private network and a public network.

Retrospective review

Part of the utilization review process that concentrates on a review of clinical information after the patient has been discharged.

Root operation restriction

Partially closing an orifice or the lumen of a tubular body part.

Individual users of the health record

Patient care providers, patient care managers & support staff, coding & billing staff, patients, employers, lawyers, healthcare researchers & clinical investigators & government policy makers.

Healthcare abuse relates to practices that may result in:

Performing medically unnecessary services.

Authorization

Permission to use or disclose PHI that is a long-standing legal requisition & health information practice; is a key component of the HIPAA Privacy Rule which states it must be obtained but there are a number of exceptions to this.

Business associates (BA)

Person or organization other than a CE workforce that performs functions & behalf of a CE; examples include consultants, billing companies, transcription companies, accounting firms & law firms, PSO, HIO & PHR vendors.

Patient-identifiable data

Personal information that can be linked to a specific patient, such as age, gender, DOB, & address.

Document imaging

Practice & technological capability of electronically scanning written or printed paper documents (like x-ray reports) into an optical or electronic system for later retrieval & access.

Present on admisison (POA)

Present at the time the order for inpatient admisison occurs, conditions that develop during an outpatient encounter including emergency department, observation or outpatient surgery.

Mutually exclusive (NCCI) edits

Prevents payment for services that cannot reasonably be billed together & applies to imporbable or impossible combination of codes.

Nominal group technique

Problem-solving technique where the group writes down their suggestions anonymously & then votes on which ideas are the most appropriate for the context of the discussion that focuses on working with individuals to find a mutally acceptable solution.

Certification

Process by which an authorized body evaluates which particular computer system, network design or application implementation meets predetermined requirements & recognizes an individual, institution or educational program who does meet the requirements.

Utilization review

Process to determine whether medical care provided to a specific patient is necessary according to pre-established objective screening criteria at time frames specified.

National Cancer Registrars Association (NCRA)

Professional organization that sponsors the CTR certification & represents cancer registrar professionals whose mission is to serve as the premier education, credentialing, & advocacy resource for cancer data professionals.

Unified Medical Language System (UMLS)

Program initiated to build an intelligent, automated system that can understand biomedical concepts, words, and expressions and their interrelationships.

Minimum compliance with CDI regulations

Progress, response & changes are to be documented, health record should be completely legible & past and present diagnosis should be easily accessible.

Beneficence

Promoting good for others or providing services that benefit others, such as releasing a record that will help someone.

Security

Protection of the privacy of individuals and the confidentiality of the health records.

HIPAA

Provides standards regarding administrative requirements that are important to the health information professional, including requirements for privacy training. Every member of the CE's workforce must be trained in PHI policies & procedures to include maintaining the privacy of patient information, upholding individual rights guaranteed by the Pirvacy Rule and reporting alleged breaches and other Privacy Rule violations.

Employee self appraisal

Provides the opportunity for the employee to kep the supervisor informed of accomplishment and issues.

Treatment

Providing, coordinating, or managing healthcare or healthcare-related services.

Law can be classified as:

Public or private

Root operation extraction

Pulling or stripping out or off all or a portion of a body part by the use of force.

Root operation reattachment

Putting back in or on all or a portion of a separted body part to its normal location or other suitable location.

Focused review

Quality data review based on specific problem areas that comes after an initial baseline review has been completed in a hospital

Coding productivity is measured by:

Quantity & quality.

Gross autopsy rate

Rate that compares the number of autopsies performed on hospital inpatients to the total number of inpatient deaths for the same period of time.

Incidence

Rate that describes the probaility or risk of illness in a population over a period of time.

Gross hospital death rate

Rate used to compare the number of inpatient deaths to the total number of inpatient deaths and discharges.

Data's purpose in healthcare

Recomended common data elements to be collected in health records.

Coinsurance

Refers to the amount the insured pays as a requirement of the insurance policy which is a percentage of the cost; calculation is done by taking the actual amount and times that by the % to get the copay amount.

Confidentiatliy

Refers to the expectation that the personal information shared by an individual with a healthcare provider during the course of care will be used only for its intended purpose.

Performance appraisal

Refers to the formal system of review and evaluation methods used to assess employee and team performance.

Public health activities disclosure

Release of birth and death information that does not require patient authorization to public health authorities.

Purging records

Removing health records of patients who have not been treated at a facility for a specific period of time from the storage area to allow space for more current records.

Dashboards

Reports of process measures to help leaders follow progress to assist with strategic planning.

Medical history

Represents documentation of the patient's current & past health status

Percentages

Represents wedges or divisions in a pie graph.

Maintaining integrity in the health record

Require periodic training covering the falsification of information and information security, prohibit the entry of false information into any of the organization's reocrds, and specify consequences for the falsificaiton of information.

Centers for Medicare & Medicaid Services (CMS)

Responsible for Medicare and parts of Medicaid and the oversight of HIPAA administrative simplification transaction & code sets, health identifiers & security standards; who publishes & maintains HCPCS medical code set, Medicare RD Remark codes administrative code set.

Cheif Privacy Officer

Responsible for privacy practices within the organization, performs privacy risk assessments, overseeing privacy training.

Root operation repair

Restoring, to the extent possible, a body part to its normal anatomic structure and function.

Undercoding

Results when diagnoses or procedures that should be coded are not assigned causing incomplete documentation.

Competent individuals healthcare rights

Right to consent to treatment & right to access their own PHI.

HIPAA individual rights

Rights of access, request, amendment of PHI, accounting of disclosures, request restrictions of PHI, and confidential communications to complain of privacy violations.

Semantic tag

SNOMED-CT fully specified name

Different types of code sets

SNOMED-CT, ICD-10-CM, LOINC, CPT, HCPCS, ICD-10-PCS

ICD-10-PCS Measurment root operation

Sampling & pressure measurment such as with a left heart cathertization.

Patient portal

Secure information system method of communication between the healthcare provider and the patient; allows a patient to log in to obtain information, register & perform other functions.

Physical safeguard

Security rule measures such as locking doors (computer doors) to safeguard data & various media from unauthorized access & exposures.

Gauge producitivity of virtual staff working remotely:

Set clear goals and productivity standards and see that these are met.

Clinical terminology

Set of standardized terms & synonyms that record patient findings, circumstances, events, & interventions with detail to support clinical care, decision support, outcomes research & quality improvement.

Health Information Exchange (HIE)

Sharing patient information between providers electronically.

Team member selection

Should be based on what members can contribute to the team and for the tasks that they actually can perfrom and responsibilities they can carry out, and not based purely on job title.

A feedback loop between CDI staff members & HIM managers:

Should be in place as a best practice, so that these two departments work directly with each other to obtain data about retrosepctive physician queries.

Advance Beneficiary Notice (ABN)

Should be provided to a patient when a service is not considered medically necessary, indicating that Medicare might not pay & that the patient may be responsible for the entire charge.

PI outcomes

Should be scrutinized whether they are positive and approrpriate or negative and diminishing.

Pareto chart

Similar in appreance to a bar chart but the highest-ranking value is listed as the first column and the next highest ranking is second and so forth.

Examples of long term care facilities

Skilled nursing care, subacute care, nursing (nursing homes, assisted living),.

Outpatient code editor (OCE)

Software installed to review claims prior to releasing billed data to the Medicare program that contains the NCCI edits for CPT; also component codes that were used instad of the appropriate comprehensive code and other types of coding errors can be identified too.

Statistical package

Software taht can be used to facilitate the data collection and analysis process; these simplify the statistical analysis of data and are often used in addition to spreadsheet software.

Presentation software

Software used to build slides when presenting a specific topic, idea, research data or any type of information, presentation of data and information is an important function of HIM.

Care plan

Special type of progress note that provides impressions of patient problems with specific goals & steps in patient treatment, amended as the patients condition requires, & the assessment of the outcomes of care, serves as a primary source for ongoing documentation of the resident's care, condition & need.

Elements of performance

Specific performance expectations, structures & processes that provide detailed information & the intent for each of the Joint Commission standards.

Components of AHIMA's management structure

Staff and volunteer

Data interchange standards

Standards developed in order to support and create structure with data exchanges to support interoperability; the goals are to facilitate consistent, accurate, and reproducible capture of clinical data.

External data example

Statewide data base used by a performance imporvement department each month to compare other facilities readmisison rates to other facility's rates.

Credential

Status & formal agreement granting permission by a national professional organization that is dedicated to a specific area of healthcare practice.

Types of subpoenas

Subpoena ad testificandum (seeks testimony) & Subpoena duces tecum (bring documents & other reocrds with onself).

Discharge summary

Summary of the resident's stay at a healthcare facility that is used along with the postdischarge plan of care to provide continuity of care upon discharge from the facility.

Periodic accreditation survey

Surveyors visit each facility & compares its programs, policies and procedures to a prepublished set of performance standards and review the facility's health record's patient care to determine whether the standards for care are being met.

Database life cycle

System consisting of several phases that represent the useful life of a database, including initial study, design, implementation, testing, operation, maintenance and evaluation.

Serial numbering system

System that makes a unique numerical identifier number for every encounter. Example: If a patient is admitted 5 times they will have 5 different health record numbers.

Chart tracking system

System that records the location of health records removed from the filing system and documents the return of the health records.

Examples of when accounting of PHI disclosures is not required:

TPO disclosures, pursuant to an authorization, and to meet national security or intelligence requirments.

Root operation extirpation

Taking or cutting out solid material from a body part.

Incorporating a workflow function in an electronic information system would help support:

Tasks that need to be performed in a specific sequence.

Data model

Technique for graphically depicting the structure of a computer database.

Natural language processing (NLP)

Technology that converts human language (structured or unstructured) into data that can be translated then manipulated by computer systems; branch of artificial intelligence.

Census

Term used for the number of inpatients present at any time in a healthcare facility.

Length of stay (LOS)

Term used to describe the number of calendar days that a patient is hospitalized.

Daily inpatient census

Term used to describe the number of inpatinets present at the census-taking time each day plus the number of inpatients who were both admitted and discharged after the census-taking time the previous day.

Data silo

Term used to identify a separate database or system within a department that does not integrate into the main organizational system nor can it be accessed by others outside that specific department.

Key component of the correction policy

That new and old documentaiton would be included in the same document with a comment section.

Part B Medicare claims

The National Correct Coding Initiative was developed to control improper coding leading to inappropriate payment for_______________

Acute inpatient

The UHDD's core elements were incorporated into this type of prospective payment system (PPS)

Information governance (IG)

The accountability framework & decision rights to achieve EIM that controls information;is the responsibility of executive leadership for developing & driving this strategy throughout the organization; Encompasses both DG & ITG.

Spoliation

The act of destroying, changing, or hiding evidence intentionally.

Accreditation

The act of granting approval to a healthcare organization based on whether the organization has met a set of voluntary standards.

Bed turnover rate

The average number of times a bed changes occupants during a given period of time.

Case Mix Index (CMI)

The average relative weight of all cases treated at a facility which reflects the resource intensity or clinical severity. Is calculated by dividing the sum of the patient's DRG weights by the total number of patients discharged.

Interoperability

The capability of different information systems & software applications to communicate & exchange data electronically from one information system to another while maintaining the original meaning.

Assigning E/M codes for hospital outpatient services:

The coder should follow the hospital's own internal guidelines to determine the level of the visit.

When unclear documentation is found in the health record

The coding professioanl should Query a physician (usually attending) who originiated the progress note or other report in question.

Data management

The combined practices of HIM, IT, and HI that affect how data and documentation combine to create a single business record for an organization

Data relevancy example

The creation of templates to collect the correct information during an emergency visit.

Duplicate record

The creation of two or more medical record numbers.

Maintain patient identity data integrity

The data must be accurately queried.

Data currency

The data within the record needs to be current & up to date.

Data

The dates, numbers, images, symbols, letters & words that represent basic facts & observations about people, processes, measurements & conditions.

Medical necessity

The determination that the services provided will benefit the patient and are needed.

Board of Directors

The elected or appointed group of officials who have the primary responsibility of setting the overall direction of a hospital & successful operation of a healthcare organization.

Data quality & integrity

The evaluation of coders is recommended at least quarterly for the purpose of measurement and assurance of ______________

Data integrity

The extent to which healthcare data are complete, accurate, consistent, and timely & a security principle that keeps information from being modified or otherwise corrupted either maliciously or accidentally.

Data consistency

The extent to which the healthcare data are reliable and the same across applications.

Process steps of expert determination of de-identification

The facility should choose the expert for the deidentificaiton analysis, determine the statistical & scientific method to be used to determine the risk of reidentificaiton, the expert applies the method to the deidentified data and analyze and assess the risk of the deidentified data.

National Center for Health Statistics (NCHS)

The federal agency responsible for collecting & disseminating information on health services utilization & the health status of the population in the US; developed & maintains ICD-10-CM.

SWOT threat example

The hospital across town recently sent all their coders home to work remotely. Currently all coding done at Helen's hospital is done in house so they do remote coding done by the other hospital.

Data abstraction

The identification of data elements by an individual through health record review.

Once a year

The least amount of time that an organization's security policies & procedures should be reviewed.

Coding assignment for multiple skin lacerations:

The length of reparis must be added together and one code is assigned.

Overall information governance model

The management of health information is a fundamental component

Average length of stay (ALOS)

The mean length of stay for hospital inpatients discharged during a given period of time. Usually 25 days or less.

APC assignment

The number is based on the number or reimbursable procedures or services provided for the patient; may be an unlimited number per encounter for a single patient.

Work measurement formula

The number of charts (work completed) divided by the number of hours worked.

Hospital's gross death rate

The number of inpatient deaths for a given period of time divided by the total number of live discharges & deaths for the same time period.

Clinical observations

The observations of physicians, nurses & other caregivers in order to create a chronological report of the patient's condition & response to treatment during their hospital stay.

Performance monitoring is data driven:

The organization's leadership uses the information displayed on a dashboard to guide operations & determine improvement projects.

Physical examination

The physicians assessment of the patient's current health status after evalauting the patient's physical condition, can include documentation of ROS

Point of care (POC)

The place or location where the physician administers services to the patient.

Office of the National Coordinator for Health Information Technology (ONC)

The principal federal entity charged with coordination of nationwide efforts to implement & use the most advanced HIT & electronic exchange of health information that was created as part of the ARRA.

Redisclosure

The process of releasing health record documentation originally created by a different provider.

Bed occupancy ratio

The proportion of beds occupied, defined as the ratio of inpatient service days to bed count days during a specified period of time.

Autopsy rate

The proportion or percentage of deaths in a healthcare organization that are followed by the performance of autopsy.

Data security

The protection measures and tools for safeguarding information and information systems.

American Recovery and Reinvestment Act (ARRA)

The purposes of this act include preserve & create jobs, promote economic recovery, provide investments, invest in transportation, environmental protection, provide long-term economic benefits, stabilize state & local government budgets.

C-section rate

The ratio of all Cesarean sections to the total number of deliveries, including C-sections during a specified period of time.

Documentation

The recording of pertinent healthcare findings, interventions, and responses to treatment as a business record and form of communication among caregivers.

Proportion

The relation of one part to another or to the whole with respect to magnitude, quantity or degree.

Disclosure

The release, transfer, provision of access to or divulgining tin any manner of information outside the healthcare facility holding the information.

Data quality

The reliability and effectiveness of data for its intended uses in operations, decision making, and planning.

Data stewardship

The responsibilities & accountabilities associated with managing, collecting , viewing, storing, sharing, disclosing,evaluation of data collected or otherwise making use of personal health information based on business needs & strategy.

Parallel work division

The same tasks are handled simultaneously by several workers each completes all steps in the process from begining to end, working independently of the other employees.

American College of Surgeons (ACS)

The scientific & education associated of surgeons formed to improve the quality of surgical care by setting high standards for surgical education & practice that started the hospital standardization program.

Data definition

The specific meaning of a healthcare related data element.

Descriptive analytics

The summarizaiton of data.

Case fatality rate

The total number of deaths due to a specific illness during a given time period divided by the total number of cases during the same period.

Back-end speech recognition

The transcriptionists become editors, making corrections to document rather than typing it who review and edit documentation after dictation the physician cannot sign until a later time.

Implied consent

The type of permission that is inferred when a patient voluntary submits to treatment.

Standard precautions

The use of infection prevention and control measures to protect against possible exposure to infectious agents. The concept is that every individual encountered in the healthcare setting should be treated as if they have an active blood-borne pathogen disease.

Average

The value obtained by dividing the sum of a set of numbers by the number of values.

1928

The year the first professional association for health information managers was established.

Interface

The zone between different computer systems across which users want to pass information.

When a record is subpoenaed but has been purged in accordance with state retention laws:

Then a certificate of destruction should be submitted in response to the subpoena.

Input mask

This enables user keys in 10101963 to have the computer display it as 10/10/1963 format.

ROI turnaround time

Time between receipt of request and when the request is sent ot the requester; 30 days on site & 60 days off site.

Access audit logs

Time stamps that record access and use of the data elements and documents; what was viewed, created, updated, or deleted, the user's identificaiton, the owner of the record and the physical location on the network where the access occurred.

30 days

To comply with HIPAA, under usual circumstances, a CE must act on a patient's request to review or copy their information within _____________

Purpose of the present on admisison (POI) indicator

To differentiate between condisions present on admisison & conditiosn that develop during an inpatient admisison.

Purposes of healthcare data sets

To identify data elements to be collected about each patient & provide uniform data definitions.

Purpose of a risk management program

To link risk management functions to related processes of quality assessment and PI.

Goal of coding compliance programs

To prevent accusations of fraud and abuse.

Core ethical obligation of HIM professionals

To protect patient's prviacy and confidential communications

Principal goal of a corporate compliance program

To protect providers from sanctions or fines.

Always assgin codes:

To their highest level of specificity.

Inpatient record review's first step:

To verify correct assignment of the principal diagnosis.

Data management system

Tool used to collect, store, manipulate & retrieve data to track productivity such as coding productivity.

Run chart

Tool used to display data points over a period ot time to provide information about performance. Measured points of a process are plotted on a graph at regular time intervals to help team members see whether there are substantial changes in the numbers over time.

Delinquency rate

Total number of delinquent records divided by the number of discharges.

Complete worked hours formula

Total work output minus defective work equals complete worked hours OR completed work divided by the hours worked to produce total work output.

Traditional HIM role

Tracking record completion

ROI tracking system

Tracks requests for turnaround time (time between receipt of the reqest and when the request is sent) information; helps investigate an issue with ROI requests turnaround time.

Ambulatory

Treatment provided on an outpatient basis.

60 days

Under HIPAA regulations this is how many days CE's have to respond to an indivudals request for access to their PHI when the PHI is stored off-site.

Consent to use & disclose PHI

Under the Privacy Rule, healthcare providers are not required to obtain patient consent for TPOs.

Sentinel event

Unexpected occurrence involving death or serious physical injury or any process variation for which a recurrence would carry a significant chance of a serious adverse outcome; signal the need for immediate investigation & response.

Exceptions to a PHI breach

Unintentional acquistions made in good faith and within the scope of authority, disclosures where the recipient would not reasonable be able to retain the information and disclosures by a person authorized to access PHI to another authorized person at the CE or BA.

Primary key

Uniquely identifies each record in a database table.

Inpatient service day

Unit of measure used to indicate the services received by one inpatient in a 24 hour period.

Case finding method

Used to identify patients who have been seen or treated in a facility for a particular disease or condition for inclusion in a registry.

Modifier -55

Used to identify that the physician provided only postoperative care services for a particular procedure.

Scatter diagram

Used to plot points for two variables that may be related to each other in some way.

Embedded metadata

Used to track data movement from 1 system to another.

Focused audit

Used when selections of coded accounts are necessary for deeper understanding of patterns of error or change in high-rsik areas or other areas of specific concern.

360 performance appraisal method

Utilizes team members as part of the appraisal process. Some of the pros of this method are that bias is reduced by including multiple perspectives from inside & outside the organization.

Unstructured free text data should be used:

Very little or not at all in the EHR.

Dashboard

Visual display of the most important information needed to achieve one or more objectives; consolidated and arranged on a single screen; A snapshot report that graphically displays inpatient & outpatient coding volume data, employee turnover rates, and the number of claim denials due to coding errors.

Steam and leaf plots

Visual display that organizes data to show its shape and distribution, using two columns with the stem in the left hand column and all leaves associated with the stem in the right hand column.

Physician Advisor/Champion

Well-respected physician who can informally help physician community adapt to and ultimately adopt health IT. Is the communicator between CDI and an actual physician.

HCPCS Level II codes

Were developed by CMS to report health services not covered in CPT. Provided for injectable drugs, ambulance services, prosethetic devices & slected provider services & not for any DME (crutches).

Type 2 transfer

When a patient is transferred from an IPPS hospital to a hospital or unit excluded from IPPS; the full PPS payment is made to the transferring hospital and the receving hospital or unit is paid based on its respective payment system.

Qui tam

Whistleblower provision of the False Claims Act that provides a means for individuals to report healthcare information non-compliance.

What information is not required when a breach is discovered:

Who committed the breach.

Portals

Windows into information systems.

Longest timeframe the hospital can take to remain in complinace with records stored off-site:

Within 60 days.

Secondary data sources for job analysis

information obtained from subject matter experts, human resource consultants, job data banks, or competency models.

Outpatient Code Editor (OCE)

is a software program linked to the correct Coding Initiative that applies a set of logical rules to determine whether various combinations of codes are correct and appropriately represent the services provided .