Ch. 25 Health Information And Information Management Flashcards
Current Procedural Terminology, 4th Edition (CPT-4)
Codes are used to code procedures for outpatient encounters and ancillary services such as radiology and laboratory.
(Exams)
Electronic Health Record (EHR)
Electronic record of patient health information generated by one or more encounters in any care delivery setting.
Included in this information are patient demographics, progress notes, problems, medications, vital signs, past medical history, immunizations, laboratory date and radiology reports.
Health Information Management (HIM)
Allied health profession, built around the management of the healthcare record in it physical form, as well as the management of date and information within the medical record.
Medical Necessity
Healthcare services or supplies that are needed to diagnose or treat an illness, injury, condition, disease l, or its symptoms
Master Patient Index (MPI)
Is an electronic file that identifies all patients who have been admitted or treated at a healthcare organization.
Demographic Data , included in the MPI
Data that contains identifying information about the patient.
Examples; internal patient identification, persons name, date of birth, gender, race, ethnicity, address, phone #, SSN, facility identification, Universal patient identifier
- this information should be verified during registration for each visit and updated as needed.
Visit Level
Information that changes with each encounter
What are the two levels of data elements that should be included in a MPI? (Master Patient Index)
Demographic & Visit-Level
What is Health insurance portability and accountability act of ___
1996
Components of the History & Physical Illness: Chief Complaint (CC)
- Statement by the patient of signs and symptoms that caused them to seek medical care
- Example; Difficult Breathing
Components of the History & Physical Illness:
History of present illness (HPI)
A chronological description of the development of the patients illness
Ex: two episodes of shaking chills lasting a few minutes, temp of 96. Second episode at 8. No fever
History and physical
Provided a detailed information of why the patient is being seen for the current episode of care, there medical history, physical examination, a clinicians impression or diagnosis, and a plan of care.
Past medical history (PMH)
Summary of patients past illnesses, surgeries, pregnancies, allergies, & current medication
Family History
Illness and disease among past or current family members
Ancillary Reports
Results of all ancillary studies are a part of patients health record. These studies include imaging studies, laboratory work, pathology reports, and any monitoring or tracing of body functions.
( this is us )
Physician Orders
All treatments and procedures, or medications to be administered to a patient require a physician order for the purpose of diagnosing a patients illness or symptoms.
In January of _____ , requirements for an appropriate use criteria (AUC) consulting prior to any advanced diagnostic imaging order was enacted for Medicare patients and AUC consults must be documented for reimbursement.
2020
Revenue Cycle
Process of patient financial and health information moving into, through, and out of the healthcare organization, culminating with the healthcare organization receiving reimbursement for services provided.
Medial necessity is the part of the _____ . Within the revenue cycle
Front-end process, if a patient presents for an exam and the physicians order is lacking a diagnosis or a diagnosis that does not meet medical necessity the provider should should be contacted immediately.
The middle process pf the revenue cycle includes the process of clinical coding.
What is ICD-10-CM?
Code used for diagnostic coding.
- the diagnosis, symptom, or reason for visit is documented by the physician is translated into ICD-10-CM codes.
CPT-4?
Codes are used to code procedures for outpatient encounters and ancillary services such as radiology and laboratory.
- Exams
_____ are designed to manage healthcare data.
- Health information systems
- this allows for sharing or protected health information across the healthcare enterprise
PACS
- Picture archiving and communication system
- refers to a networked group of computers, servers, and achieves to mange digital images.
Define health informatics?
The interdisciplinary field that works to improve health and healthcare
Which organization accredits hospitals and other health care institutions in the United States?
The joint review committee
The chief complaint, included in a patient history is a statement made by the ?
Patient
The Health Insurance Portability & Accountability Act of 1996 (HIPPA) legislation affects radiology & other hospital departments by its focus on ?
Patient record confidentiality
When a physician orders a diagnostic exam, what must be included on the order?
The diagnosis or symptoms
What is used to assign codes for the diagnostic exam?
CPT-4
Which part of the HIPAA privacy rule requires workforce training to ensure patient privacy?
Administrative Requirements
Which system is designed to manage imaging orders?
RIS
Which technology is used to identify and classify cancer?
Artificial Intelligence
What is typically documented in a History & Physical?
Chief Complaint
History of present illness
Review of systems
Past medical history
Family history
Social history
Physical examination
Impression or diagnosis and treatment plan
