RHIA Domain 1
Components of __________ record: data on the patient's menstrual history, obstetric history, medical and surgical history, physical exams, nutritional evaluation, behavioral evaluation, lab test results, high risk evaluation, documentation on obstetrical education, and a plan of care based on physical exam.
prenatal
How long must a healthcare entity maintain a certificate of destruction?
permanently
Which type of documentation is this? represents the physician's assessment of the patients current health status after evaluating the patient's physical conditions
physical exam
Components of __________ record: medical, family, social history, vital signs, chief complaint, progress notes, allergies, medication list, HPI, ROS, assessment and diagnosis, plan of treatment
physician office
________ data source: contains information about a patient that has been documented by the professionals who provided care or services to that patient
primary
Consists of a problem list, the history and physical examination and initial lab findings, the initial plan, and progress notes
problem oriented health record
SOAP methodology came from:
problem oriented health record
Which filing system is often used by small clinics and physician offices?
Alphabetic
Another word for outpatient
Ambulatory
Four major purposes for collecting secondary data
(1) Quality, performance, and patient safety (2) Research (3) Population health (4) Administration
Purpose of the legal health record (3)
1. To support decisions made in the course of treating a patient, 2. support documentation for the revenue pursued by payers, 3. and documentation used for legal testimony related to the patient's disease, injury, treatment, the decisions related to it and the response to it
Medicare retention rate of health records
10 years
What kind of entity relationship is this? Patients to hospital beds
1:1
What modifier would you use for a patient who returns during the post-op period and is now complaining of a different problem?
24
Do not use modifier ____ for: post-op period, if there is only an E&M service and no procedure, or if an E&M service with a minimal procedure performed on same day unless can be reported as significant
25
Which modifier? Significant, Separately Identifiable E&M service by the same physician on the same day of the procedure or other service
25
What modifier? Physician performs the professional component only.
26
How long do cancer records have to be maintained according to the FDA?
30 years
How long must health records be retained according to CoP
5 years
Which modifier? Distinct Procedural Service - used to indicate that two or more procedures were performed during the same visit to different sites on the body
59
What modifier? Repeat tests are performed on the same day by the same provider to obtain reportable test values with separate specimen taken at different times
91
Who is Level 1 of CPT updated by? How often?
AMA, annually
a permanent log of all the cases entered into the database
Accession register
What programs does TJC accredit?
Ambulatory, behavioral, critical access hospitals, homeware, hospital, laboratory, nursing care centers, physician offices, and office-based surgery centers
Requires a facility to maintain a single case record for any patient it admits.
CARF
If healthcare organizations want to participate in federal government reimbursement programs, they must at least demonstrate they meet the:
CFCs and CoPs
If an organization meets TJC accredited deemed status survey, they are also deemed to have met the __________ requirements
CMS
federal agency within the US Dept of Health and Human Services. Known for its operational oversight of the Medicare program and in collaboration with state government programs. Also plays an important regulatory role in an organizations medical staff makeup and the content of the medical staff bylaws
CMS
the administrative policy and procedure requirements and operational guidelines (how the policies and procedures are carried out) under which facilities are allowed to take part in the Medicare and Medicaid programs- CMS dictates medical staff bylaws must address certain documentation requirements
CMS Conditions of Participation
all of the patients encounters are filed together in a single location
Centralized unit filing system
The process by which a duly authorized body evaluates and recognizes an individual, institution, or educational program as meeting predetermined requirements
Certification
CARF acronym
Commission on Accreditation of Rehabilitation Facilities
Standards applied to facilities that choose to participate in federal government reimbursement programs such as Medicare and Medicaid
Conditions for Coverage (CFCs)
Purposes of a discharge summary (3)
Ensures continuity of care, provides information to support the activities of the medical staff, provides concise information that can be used to answer information requests
DEEDS
Data Elements for Emergency Department Systems. Recommended data set of hospital based ED
A listing of all the data elements within a specific system that defines each individual data element, standard input of the data element, and specific data length
Data dictionary
An official designation indicating that a healthcare facility is in compliance with the Medicare Conditions of Participation
Deemed status
What is the first step a healthcare entity should take when developing a data dictionary?
Design a plan
software program and supporting hardware that automate and integrate the records management process.
Electronic document management system
What act prohibits healthcare providers from refusing to treat patients or delaying treatment due to the patient not having insurance or not having the ability to pay?
Emergency Medical Treatment and Active Labor Act (EMTALA)
A patient had a radical resection of soft tissue sarcoma of left thigh. What is the root operation?
Excision
When are pharmacy consults required?
For elderly patients who take multiple medications
When must a medical history and physical (H&P) be documented?
For every patient no more than 30 days before or 24 hours after admission to the hospital
How do healthcare providers use the administrative data they collect?
For regulatory, operational, and financial purposes
What is the MEDPAR file frequently used for?
For research on topics such as charges for particular types of care and DRGs.
What document required by TJC should be placed in the patients health record prior to a surgical procedure?
H&P
A major initiative of the AHRQ. Uses data collected at the state level from either claims data from the UB-04 or discharge-abstracted data, including UHDDS items reported by individual hospitals and, in some cases, by freestanding ambulatory care centers
HCUP
Additional privacy regulations on top of HIPAA, breach notification rules & stiffer civil and criminal penalties for security violations
HITECH Act
-oversees most clinical and administrative data such as demographics, reports, claims, and orders -holds patient full medical information from hospital billing to the inpatient ordering system -is the standard generally used in communication between the hospital information system (HIS) and the RIS
HL-7 (health level 7)
HCUP acronym
Healthcare Cost and Utilization Project
Purposes of defining a data dictionary
Help with accuracy of patient data and rate support for data comparison and sharing
Describes body functions and structures, activities and participation
ICF
When is a discharge summary unnecessary?
If the patient's stay is not complicated and lasts less than 48 hours OR involves an uncomplicated delivery or normal newborn (O40)
ICF acronym
International Classification of Functioning, Disability and Health
Which classification system was developed to standardize terminology and codes for use in clinical laboratories?
LOINC
__________ provides names and codes for identifying lab and clinical test results or clinical observation
LOINC
common language (set of identifiers, names, and codes) for identifying health measurements, observations, and documents.
LOINC
LOINC acronym
Logical Observations, Identifiers, Names, and Codes
Overall RAI framework includes
MDS, triggers, utilization guidelines, and resident assessment protocols (RAP)
What setting are these data sets used in? MDS UHDDS OASIS DEEDS
MDS- long term care UHDDS- acute, short, long term care in hospitals OASIS- home health DEEDS- ED
The National Library of Medicine produces two databases of special interest to the HIM professional:
MEDLINE and UMLS (Unified Medical Language System)
Made up of acute-care hospital and skilled nursing facility claims data for all Medicare claims. Consists of this type of data: demographic, data on the provider, information on Medicare coverage for the claim, total charges, charges broken down by specific types of services, ICD-10-CM diagnosis and procedure codes, and DRGs.
MEDPAR
The set of standards defined by the CMS Incentive Programs that governs the use of EHRs and allows eligible providers and hospitals to earn incentive payments by meeting specific criteria
Meaningful Use (MU)
Standards governing the practice of medical staff members; typically voted upon by the organized medical staff and the medical staff executive committee and approved by the facility's board; governs the business conduct, rights, and responsibilities of the medical staff; medical staff members must abide by these bylaws in order to continue practice in the healthcare facility
Medical staff bylaws
Inpatient rehab hospitals and units within hospitals are reimbursed by __________ under a prospective payment system
Medicare
MEDPAR acronym
Medicare Provider Analysis and Review
a strategic plan that identifies applications, technology, and operational elements needed for the overall IT program in a healthcare entity
Migration path
a detailed form with guidelines for assessing residents in long-term care facilities; also details what to do if resident problems are identified
Minimum Data Set (MDS)
A repository of information about health care practitioners, established by the Health Care Quality Improvement Act of 1986
NPDB (National Practitioner Data Bank)
What are the limitations of MEDPAR data for research purposes?
Only contains data about Medicare patients
Components of what report? patients preoperative and postoperative diagnosis, descriptions of the procedures performed, descriptions of all normal and abnormal findings, a description of the patient's medical condition before during and after the operation, estimated blood loess, descriptions of any specimens removed, descriptions of any unique or unusual events during the course of the surgery, name of surgeons and their assistants, date and duration of surgery.
Operative report
What index would be used to compare the number and quality of treatments for patients who underwent the same operation with different surgeons?
Physician index
Who is responsible for ensuring the quality of health record documentation?
Provider
How often is HCPCS updated by CMS?
Quarterly
R-ADT system (acronym and purpose)
Registration-admission, discharge, and transfer system. For tracking in-house patients who have been transferred to a specialty unit
Components of __________ record: patient ID data, pertinent history (including functional history), diagnosis of disability and functional diagnosis, rehabilitation problems, goals, and prognosis, reports of assesments and program plans, reports from referring sources and service referrals, reports from outside consultations and lab radiology orthotic and prosthetic services, designation of a manager for the patients program, evidence of patients/familys participation in decision making, evaluation reports from each service, reports of staff conferences, progress reports, correspondence related to the patient, release forms, discharge summary, follow up reports
Rehabilitation
What is the federal regulated care plan called for skilled nursing facilities?
Resident assessment instrument
___________ normalizes names and unique identifiers for clinical drugs and links its names to the varying names of drugs present in many different vocabularies within the Unified Medical Language (UML)
RxNorm
A classification system designed with electronic systems in mind, currently used for problem lists, ICU unit monitoring, patient care assessments, data collection, medical research studies, clinical trials, disease surveillance, and image indexing.
SNOMED-CT
patient issued unique numerical identifier for every encounter at the facility
Serial numbering system
combination of serial and unit. Patient is issued a new health record number with each encounter but all of the documentation is moved from the last number to the new number.
Serial unit numbering system
What information is necessary to know for coding skin grafts?
Size, type of repair, and recipient site
Meaningful Use Stages
Stage 1: Data capture and sharing Stage 2:Advance clinical processes Stage 3:Improved outcomes
a piece of legislation written and approved by a state or federal legislature and then signed into law by the state's governor, or President of the United States
Statute
files records in straight numeric order based on health record number
Straight numeric filing system
SNOMED-CT acronym
Systematized Nomenclature of Medicine - Clinical Terms
A system of health record identification and filing in which the last digit or group of digits (terminal digits) in the health record number determines file placement
Terminal-digit filing system
Designated multidisciplinary body for the administrative oversight, development, and review of cancer care services at a facility. Communicates directly with the facilities medical board, and its activities and recommendations directly impact programs
The Cancer Committee
An organization that accredits health care organizations and programs
The Joint Commission (TJC)
What government agency has led the development of basic data sets for health records and computer databases?
The National Committee on Vital and Health Statistics
Used for reporting inpatient data in acute care, short-term care, and long-term care hospitals. Minimum set of items based on standard definitions to provide consistent data for multiple users. Required for reporting Medicare and Medicaid patients. Many other health care payers also use most of the UHDDS for the uniform billing system.
Uniform Hospital Discharge Data Set (UHDDS)
Patient is issued a health record number at the first encounter and that number is used for all subsequent encounters.
Unit numbering system
ICF was developed by
WHO
Value used in ICD-10-PCS if there is a character that does not apply to a given code
Z
The ____________ number consists of the first digits of the year the patient was first seen at the facility, with the remaining digits assigned sequentially throughout the year.
accession
Coded information contained in secondary records describing patient identification, diagnosis, procedures, and insurance
administrative data
legal documents that allow you to spell out your decisions about end-of-life care ahead of time.
advance directive
____________ data: include data on groups of people or patients without identifying any particular patient individually. Example: statistics on the average length of stay for patients discharged with a particular DRG
aggregate
Components of __________ record: registration forms including patient ID data, problem lists, medication lists, patient history questionnaires, history and physicals, progress notes, results of consultations, diagnostic test results, misc flow sheets, copies of records of previous hospitalizations/ treatment by other providers, correspondence, consents to disclose information, advance directives
ambulatory
Components of __________ record: history and physical and consent prior to procedure, operative reports and notes, diagnostic and therapeutic documentation, consultations, and discharge notes at conclusion of treatment, discharge follow-up phone calls
ambulatory surgery
Tests and procedures ordered by a physician to provide information for use in patient diagnosis or treatment OR professional healthcare services such as radiology, lab, PT
ancillary services
Systems that serve primarily to manage the department in which they exist, while at the same time providing key clinical data for the EHR
ancillary systems
Ancillary function of the EHR
biomedical research
An accumulation of numeric or alphanumeric representations or codes for exchanging or storing information is a _______________-
code system
Which type of documentation is this? summary of the patients problems from the nurse or other professionals perspective with a detailed plan for interventions. Follows the assessment
care plan
These are examples of ______________: SNOMED CT, ICD, LOINC
code system
__________ coding is completed while the patient is still admitted to the facility whereas ___________ coding is completed after the patient is discharged from the facility
concurrent, retrospective
Consult or referral? _______ is the equivalent of advice. _________ refers to taking over continuum of care
consult, referral
A diagnosis described as "possible" "probable" "likely" or "rule out" is reported as if present for which type of patient records?
inpatient
Primary advantage of using standardized data sets for collecting healthcare information
data can be compared nationally
Term for decision making and authority over data-related matters
data governance
processing of extracting from a database or data warehouse information stored in discrete, structured data format.
data mining
a single database that makes it possible to access data that exists in multiple databases through one single query and reporting interface
data warehouse
process of collecting the data from different data sources within an organization and storing it in a single database that can be used for decision making
data warehousing
factual details aggregated or summarized from a group of health records that provides no means to identify specific patients
derived data
Components of a __________: concise account of patient's illness, course of treatment, response to treatment, condition at time of treatment, and instructions for follow up care
discharge summary
a listing of specific codes (ICD) that link a specific disease or diagnosis to a patient
disease index
exists when person executes a power of attorney which will become or remain effective in the event he or she should later become disabled
durable power of attorney
The RAI is electronically submitted first to ______________ and then to __________
each state health department, CMS
Components of __________ record: patient demographic information, arrival time, means of arrival, name of person bringing the patient, pertinent history of illness, physical findings, diagnostic tests, treatment provided, disposition, condition of patient upon discharge, patient discharge instructions, signatures of patient
emergency department
Primary responsibility of a coder is to
ensure accuracy of coded data
Graphical display of relationships between tables in a database
entity relationship diagram
Skilled nursing facilities are governed by :
federal and state regulations, including Medicare CoP
Which type of documentation is this? snapshot of a patient's status and includes everything from social issues to disease processes as well as critical paths and clinical pathways that focus on a specific disease process or pathway in a long-term care hospital
flow sheet
Records consisting of multiple electronic systems that do not communicate or are not logically architected for record management
hybrid health records
The business of collecting information and selling it to other organizations
information brokering
Components of __________ record: history and physical, consultation reports, physicians orders and progress notes, nursing assessment and progress notes, and discharge summary
inpatient
Components of __________ record: fetal monitoring strips, a record of medications given and stopped, nursing progress notes, events that occur during birth including time and type of delivery
labor and delivery
Components of __________ record: registration forms, personal property list, history and physical and hospital records, advance directives, bill of rights and other legal records, clinical assessments, RAI and care plan, physician's orders, physician's progress notes and consultations, nursing notes, rehab therapy notes, social services, nutritional services, and activities documentation, lab radiology and special reports, discharge or transfer documentation
long term care
What kind of relationship is this? Patients to consulting physicians
many to many
a guide to locating specific demographic information about a patient such as the patient name, health record number, date of birth, gender and dates of service
master patient index
Which type of documentation is this? addresses the patient's current complaints and symptoms and lists his or her past medical, personal, and family history.
medical history
Components of _________: chief complaint, past and present illnesses, family history, social history, and review of body systems must be documented prior to surgery/ procedure requiring anesthesia
medical history and physical (H&P)
Vocabulary of clinical and medical terms used by health care providers to document patient care
medical nomenclature
A data element name is an example of
metadata
Advantages of terminal digit filing system
most effective for facilities with heavy record volume and distributes charts evenly throughout the filing units
Components of __________ record: examination performed upon birth, exam prior to discharge, physical condition immediately after birth, physical condition eval regarding distress and needs of additional care, APGAR, physician's orders, nursing notes, and progress notes.
newborn
Practice or methods that defend against charges questioning the integrity of the data and documents
nonrepudiation
database designed to store different types of data including images, audio files, documents, videos, and data elements
object oriented database
Because a stay for a patient or resident in long term settings can be lengthy, health records are based on :
ongoing assessments and reassessments of the patients needs
a listing of specific codes for procedures or operations performed within the facility
operation/ procedure index
A _________ is completed shortly after admission and upon discharge at an inpatient rehab hospital
patient assessment instrument
A ________________ is completed shortly after admission and upon discharge at an inpatient rehab hospital
patient assessment instrument (PAI)
CMS CoPs and CFCs (conditions for coverage) ensure:
patient care quality, safety, and improvement of clinical outcomes
____________ component is provided by the physician and may include supervision, interpretation, and a written report. The ____________ component includes the provision of all equipment, supplies, personnel, and costs related to the performance of the exam
professional, technical
database that stores data in tables that are predefined and contain both rows and columns of information
relational database
problem-oriented frameworks for additional patient assessment based on problem identification items (triggered conditions) in a long-term care settings
resident assessment protocols (RAPs)
Data derived from the primary patient record, such as an index or a database are considered:
secondary data sources
Principal function of healthcare
serve as the repository of clinical documentation relevant to the care of individual patients
What type of format? Traditional paper format for a hospital patient care record
source oriented
Assisted living facilities are governed by
state regulations
Binary, machine-readable data in discrete fields; data able to be processed by the computer
structured data
The data elements in a patients automated lab result are examples of
structured data
Review of systems is _________ and physical exam is __________ (objective/subjective?)
subjective, objective
A legal document requiring the recipient to bring certain written records to court to be used as evidence in a lawsuit
subpoena duces tecum
Numbering system commonly used in large healthcare facilities
unit numbering
Nonbinary, human-readable data
unstructured data
Most long term care providers do not participate in:
voluntary accreditation programs
