Chapter 25 Flashcards
health information management
the allied health profession built around the management of the healthcare record in its physical form, as well as the management of data and information within the medical record
health informatics
the interdisciplinary field that studies and pursues the effective uses of biomedical data, information and knowledge for scientific inquiry
HIPAA
Health insurance portability and accountability act
medical necessity
healthcare services or supplies that are needed to diagnose or treat an illness, injury, condition, disease
revenue cycle
process of patient financial and health information moving into, through, and out of the healthcare organization
clinical informatics is also referred to as:
applied clinical informatics
operational informatics
which patients are listed individually in the MPI?
all patients registered to receive care as inpatient/outpatient
what information is included in a visit level data in an MPI?
account/visit number
admission date
discharge date
encounter/service type
location
primary physician
patient disposition
what information does the history and physical provide?
why patient is being seen, medical history, physical exam, physicians impression/diagnosis, plan of care
what is the specific timeframe completion of the history and physical for inpatients?
24 hours
what is an operative report?
descriptions of the details of a surgical procedure
ancillary studies include what?
imaging studies, labs, pathology reports, monitoring/tracings
what can physicians use to send orders directly to an ancillary department?
computerized physician order entry (CPOE)
what is the code set used for diagnostic coding? example?
ICD-10-CM
international classification of diseases, 10th edition, clinical modification
R05-Cough; R06.02- SOB
what is used to code procedures for outpatient encounters and ancillary services? example?
CPT-4
current procedural terminology 4th edition
71046 - radiologic exam, chest; 2 views
what supports the need for timely access to health information, and the EHR remains secure and patient information remains private?
HIPAA
what allows for the sharing of information between disparate information systems?
interoperability
what does HIS stand for and what does it typically include?
health information systems
manage healthcare data
what does RIS stand for and what is it responsible for?
radiology information system
management of imaging orders, scheduling, billing, tracking, reporting
what does PACS stand for?
picture archiving and communication system
