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Healthcare Documentation Essentials > 8, 9, 10 > Flashcards

8, 9, 10 Flashcards

1
Q

If data conforms to an expected range of values is has…

A

Data Integrity

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2
Q

What is the vocabulary of clinical and medical terms?

A

Medical Nomenclature

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3
Q

What is an automated of manual process performed by health information department staff to collect patient information to determine prospective payment system status, generate indexes, and report data to quality improvement organizations and federal and state agencies?

A

Case Abstracting

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4
Q

What is is called when a doctor fails to exercise the degree of care considered reasonable under the circumstances, resulting in an unintended injury to another party?

A

Negligence

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5
Q

What is is called if data is accurate, complete, consistent, up to date, and the same no matter where it is recorded?

A

Data Integrity

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6
Q

Telephone Order

A

TO

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7
Q

What is information that is identifiable to an individual such as name, address, telephone numbers, DOB, Medical ID#, MR#, SS#, or name of employer?

A

Protected Health Information (PHI)

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8
Q

Hx

A

History

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9
Q

What is an organized system for the collection, storage, retrieval, analysis, and dissemination of individuals who have either a particular disease, or a condition that predisposes them to the occurrence of a health related event, or have prior exposure to substances or circumstances known to cause adverse side effects?

A

Registry

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10
Q

Dx

A

Diagnosis

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11
Q

WNL

A

Within Normal Limits

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12
Q

DC IV

A

Discontinue Intravenous

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13
Q

TKA

A

Total Knee Arthroplasty

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14
Q

COPD

A

Chronic Obstructive Pulmonary Disorder

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15
Q

LAP CHOLE

A

Laparoscopic Cholecystectomy

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16
Q

ROS

A

Review of Systems

17
Q

DAT

A

Diet as Tolerated

18
Q

What is it called when software is used to search for patients and trends and to produce data content relationships?

A

Data Mining

19
Q

What is a public or private entity that processes or facilitates the processing of health information received from another entity from a non standard to a standard format?

A

A Clearinghouse

20
Q

What is any information communicated by a patient to a health care professional?

A

Privileged Communication

21
Q

What is a written command signed by the clerk of court, ordering an individual to appear in court with documents?

A

Subpoena Duces Tecum

22
Q

What is the federal agency responsible for maintaining vital statistics?

A

The National Center For Health Statistics (NCHS)

23
Q

What is the study of types of patients treated by a facility called?

A

Case Mix Ananlysis

24
Q

What is if called when a set of data is summarized using charts, graphs, and tables?

A

Descriptive Statistics

25
Q

What is the number of inpatients present at census taking time called? (usually midnight)

A

Daily Census Count

26
Q

What is a document that lists all the procedures, services, and supplies provided to patients by a hospital and also from patients to a hospital?

A

Chargemaster

27
Q

What is the legal process that lawyers use to obtain information about all aspects of a case?

A

Discovery

28
Q

What is it called when you divide the total length of stay by the number of patients discharged?

A

The Average Length of Stay

29
Q

What is a guide to point out or otherwise facilitate reference of names, places, and subjects, by giving the page or page numbers on which each item is listed?

A

Index

30
Q

What is the physiologic complexity that compromises the extent and interactions of a patient’s disease as presented to medical professionals?

A

Severity of Illness

31
Q

What is a formal or official recording of names, actions, or items?

A

Register

32
Q

What is a form of discussion that includes a list of written question that must be answered by the party served?

A

Interrogatory

33
Q

What is failure to obey a subpoena, which is punishable by fine or imprisonment called?

A

Contempt of Court

34
Q

When a healthcare provider acts in an improper or negligent manner and the result is injury, damage, or loss to the patient it is called…

A

Malpractice

35
Q

What are federal regulations that healthcare organizations must meet to participate in the Medicare and Medicaid programs?

A

Conditions of Participation

Healthcare Documentation Essentials (6 decks)

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