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Diagnosis Related Groups

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Inpatient hospital cases classified into groups that are expected to consume similar hospital resources. Example: Hospital inpatient are discharged once the acute illness has passed and are transferred to outpatient care facility such as rehab. home health care.

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Purpose of the Joint Commission

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To help health care facilities get accreditation and maintain them. It's approach is patient-centered and data-driven. They have been doing this since 1951.

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RHIT job titles

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Certified Professional Coder, Cancer Registers

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Administrative Simplifications

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Scheduled diagnostic and therapeutic services

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Subscribers

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policyholders; members of an insurance benefit plan

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General Hospitals

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Provide emergency care, perform general surgery, and admit patients for a range of problems from fractures to heart disease, based on licensing by the state.

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Clinical Data

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All patient information obtained through treatment and care of the patient. Includes health care information obtained about a patient's care and treatment, which is documented on numerous forms in the patient record.

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Correcting a documentation error

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Put a single line threw the error and sign you name along with the time and date and write down why you crossed out the error. Example: wrong chart, wrong dose of drug.

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Abbreviation List

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include medical staff approved abbreviations, acronyms, and symbols that can be documentd in patient records.

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EHR

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Electronic Health Record -The consolidation of all of the recorded health information about a person stored withing a given network. EHR's generally contain multiple EMR's collected from various facilities and providers within a provider network or umbrella organization.

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Benefits of electronic Health data

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Review of Systems

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1) evaluates the past and present health state of each body system, 2) double-checks in case any significant data was omitted in the Present Illness section 3) evaluates health promotion practices--lists systems from head to toe

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Admitting diagnosis

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The patient's condition determined by a physician at admission to an inpatient facility.

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Discharge Order

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A doctors' order that states that the patient may leave the hospital. A doctors' order is necessary for a patient to be discharged from the hospital

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Decentralized filing

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Type of filing system where patient records are organized throughout the facility in patient care areas under control of the department that creates and uses them.

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Medical Malpractice

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Results when a health care provider acts in an improper or negligent manner and the patient's result is injury, damage, or loss.

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Breach of Confidentiality

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When confidential information is disclosed to a third party without patient consent or court order.

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APC Payment to Hospitals

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Ambulatory payment classification-Medicare implemented this in 2008

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NLA and Medicare

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Record Retention

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length of time , record kept by a facility called a record retention schedule, record meets legal and regulatory requirements achieve accreditation allows. Examples are: paper, microfilm,magnetic tape,optical disk,or part of an electronic system computer.

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Off site storage

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Location separate from the facility used to store records. Also called remote storage.

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Time period to initiate a lawsuit

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Shadow Record

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Paper record that contains copies of original records and is maintained separately from the primary record.

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WHO

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World Health Organization in 1946 they helped revise ICD-6 and established an International List of Causes of Morbidity-they review and revise ICD every 10 years

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CPT

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Current Procedural Terminology-Published annually by the American Medical Association; codes are five-digit numbers assigned to ambulatory procedures and services.

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Audit control

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Respondeat superior

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"Let the master answer" an employer is vicariously liable for the behavior of an employee working within his or her scope of employment

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Master patient index

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Links a patient's medical record number with common identification data elements also called master person index

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Registers and registries

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Case Abstracting

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The automated or manual process performed by health information department staff to collect patient information to determine prospective payment system (PPS) status, generate indexes, and to report data to quality improvement organizations and state and federal agencies.

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Data Set

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Establishing a standard method for collecting and reporting individual data elements so data can be easily compared.

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Governing Board

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Membership serves without pay and is represented by professionals from the business community; has ultimate legal authority and responsibility for the hospital's operation and is responsible for the quality of care administered to patients; also called board of trustees, board of governors, board of directors.

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Ophthalmology

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Specializes in the study, diagnosis, and treatment of disorders of the eye.

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Credentials Committee

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Reviews and verifies medical staff application data

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Admitting Department

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Utilization Management

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Controls health care costs and the quality of health care by reviewing cases for appropriateness and medical necessity.

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HIM services

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Incomplete-record processing

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Includes the assembly and analysis of discharged patient records.

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Risk Management

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Promotes the delivery of quality health care and safety, receives all incidents reports, they work with lawyers and insurance company's when a lawsuit has been filed, helps to identify risks in the workplace to control injury's

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Cancer Registrar

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collects cancer data from a variety of sources and reports cancer statistics to government and health care agencies. (e.g., state cancer registries); also called a tumor registrar.

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AAPC

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American Academy of Professional Coders-types or certification you can get are (CPC)-certified professional coder/ (CPC-H)-certified professional coder-hospital/and each has apprentice status/(CPC-A /CPC-H-A) (CPC-P) certified professional coder payer and plenty of others.

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Networking

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...

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Medical Transcriptionist

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Transcribe prerecorded dictation, creating medical reports, correspondence, and other administrative material.

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Acute care facility

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a health care facility that provides care for patients who have serious, sudden, or acute illness or injuries and/or need certain surgeries.

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Subacute hospital

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Provided in hospitals that provide specialized long-term acute care such as chemo, injury rehab, ventilator support, wound care, and other types of seriously ill patients.

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Hospice

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provides comprehensive medical and supportive social, emotional, and spiritual care to terminally ill patients and their families. Goal is palliative rather than curative.

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Closed-panel HMO

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Includes group and staff models that provide services at HMO-owned health centers or satellite clinics, or by physicians who belong to a specially formed medical group that serves the HMO.

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Physicians

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Pre admission testing

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PAT- Incorporates patients registration testing, and other services into one visit prior to inpatient admission or scheduled outpatient surgery were the results can become incorporated into the patient records

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Ancillary Reports

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Reports in the patients chart from laboratory, radiology, and nuclear medicine to assist the physicians diagnosis and treatment of patients

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Medication List

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Information regarding the dosage and frequency of the patients medication

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Progress notes

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Statements related to the course of the patient's illness, response to treatment, and status at discharge. They facilitate health care team member communication because progress notes provide a chronological picture and analysis of the patient's clinical course they do document continuity of care which is crucial to quality care.

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Patient Registration form

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date of patient's current visit, age, address, social security number, DOB, medical insurance information, person to contact in an emergency

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Problem list

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Documentation in the POR (problem oriented record) that acts as a table of contents for the patient record because it is filed at the beginning of the record and contains a list of the patients problems. Each problem is numbered which helps to index documentation throughout the record

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ICD-9-CM

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International Classification of Disease, 9th Clinical Modification

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Protected Health Information

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Information that is identifiable to an individual (or individual identifiers) such as name, address, telephone numbers, date of birth, Medicaid ID number and other medical record numbers, social security number (SSN), or name of employer.

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HIPPA

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Health Insurance Portability and Accountability Act-Mandatated Administrative simplification relations that govern privacy, security, and electronic transactions standards for health care information: also protects health insurance coverage for workers and their families when they change or lose their job.

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Data Analysis

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Process of translating data into information utilized for an application.

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Data Application

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purpose for which data are collected

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Data Warehousing

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processes and systems used to achieve data and data journals

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Data Collection

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process by which data elements are accumulated

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Data Integrity

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data that is accurate, complete consistent, up to date, and the same no matter where the data is recorded

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Data Reliability

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if it is consistent throughout all systems in which it stored, processed and or retrieved.

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Data Validity

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if it conforms to an expected range of values

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Average daily census

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average number of inpatients treated during a given time period. It is calculated for varying time periods, such as weekly, monthly, and annually.

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Daily Census Count

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number of inpatients present at census taking time

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Daily inpatient census

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official count of inpatients present at midnight, which is calculated each day.

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Advance Directive

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Legal document that provides instructions as to how patients want to be treated in the event they become very ill and there is no reasonable hope for recovery. Written instructions direct a health care provider regarding a patient's preferences for care before the need for medical treatment.

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Clinical Resume

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provides information for continuity of care and facilitates medical staff committee review: documents the patients; hospitalization, course of treatment, and condition at discharge. Also called the discharge summary.

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History of Present Illness

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Description of patients present condition from time of onset to present: should include location, quality, severity, duration of the condition,and associated signs and symptoms.

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Routine Orders

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physicians orders that are pre approved by the medical staff, which are preprinted and placed on a patient's record. Includes standard admitting orders for a surgical patient, discharge orders following surgery.

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Attending Physician

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Medical staff member who is legally responsible for the care and treatment given to a patient.

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Pathology Report

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assists in the diagnosis and treatment of patients by documenting the analysis of tissue removed surgically or diagnostically, or that is expelled by the patient: also called tissue report

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Laboratory Report

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A type of ancillary report-it documents the results from blood-urine-drug tests-cardiac enzymes-blood types. Should show the date and time of lab test, results, time it was logged into the lab, time results were determined, a reference section for range of values that your results should be in, and who the lab tech was.

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Family History

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Review of the medical events in the patient's family, including diseases which may be hereditary or present a risk to the patient

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Straight number order

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records are filed in strict chronologic order according to patient number, from lowest to highest, also called consecutive numeric filing. (111234,111235,111236)

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Terminal number order

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commonly used in health care facilities that assign six-digit (or longer) patient numbers because the number can be easily subdivided into three parts: primary, secondary, and tertiary digits. Also called reverse numeric filing. (01-01-01, 02-01-01, 03-01-01) READ NUMBERS FROM RIGHT TO LEFT

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Middle digit order

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A variation of terminal-digit filing, which assigns the middle digit as primary, digits on the left as secondary and digits no the right as tertiary. (01-01-01, 01-01-02, 01-01-03) READ MIDDLE NUMBER THEN LEFT THEN RIGHT NUMBERS

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Out guides

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Replaces the record in the file area to indicate it has been removed and to identify its current location.

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Department-oriented format

answer

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Security

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Keeping facilities, equipment, and patient information safe from damage, loss, tampering, theft, or unauthorized access.

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Data Currency

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(data timeliness) data must be collected and available to the user within a reasonable amount of time: data must also be up-to-date.

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Medication administration record

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MAR-Documents medications administered, date and time of administration, name of drug, dosage, route of administration, and initials of nurse administering medication.

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Administrative data

answer

demographic, socioeconomic, and financial information

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serial numbering system

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Each time the patient is registered, a new patient number is assigned by the provider and a new patient record is created. a patient who has multiple admissions also has multiple patient numbers. Patient records are filed in multiple locations in the permanent file system. this type of filing system is usually selected by the facilities that do not use computerized registration/admission/discharge/transfer (RADT) software.

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quantitative review

answer

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Alphabetical filing

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Patient's last name, first name, middle initial are used to file patients records-when no numbering system is selected by the facility-and to file master patient index cards-when a numbering system is used by the facility

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image processing

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physician order

answer

direct the diagnostic and therapeutic patient care activities-also called doctor's orders

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AHIMA

answer

American Health Information Association-(CCA) certified coding associate/ (CCS) certified coding specialist/ (CCS-P) certified coding specialist-physician-based

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