Chapter 3: Vocabulary Flashcards
To assist you in learning the vocabulary found throughout your text, the exam, and the industry.
Health record
Contains information relating to the physical or mental health or condition on an individual.
Data
Raw facts. Data are individual facts, statistics, or items of information collected together for reference or analysis
Information
Data that has been turned into something meaningful
Hybrid health record
A combination of a paper record and the EHR
Aggregated data
Data that has been extracted from the individual health record and combined to form deidentified information about a group of patients.
Master patient index (MPI)
The permanent record of all patients treated at a healthcare facility
Demographics
Basic information about the patient such as their name, DOB, address, and insurance information
Duplicate health record
A patient has two or more health record numbers in the same facility.
Overlay
A patient was assigned someone else’s health record number
Overlap
A patient has more than one health record number at different locations within the same enterprise
Algorithms
Used to maintain quality control in the MPI by reducing duplicates, overlays, and overlaps through matching patients so that patient information can be merged.
Deterministic algorithm
Requires an exact match of data elements
Probabilistic algorithm
Uses mathematical probabilities to determine the possibility that two patients are the same.
Rules-based algorithm
Assigns a weight to specific data elements and uses those weights to compare one record to another.
Serial numbering system
A patient is issued a unique numerical identifier for every encounter at the healthcare facility
Unit numbering system
A patient is issued a unique health record number during the first encounter and that number is used for all subsequent encounters
Serial-unit numbering systems
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.
Qualitative analysis
Monitors the quality of documentation to ensure that quality standards are met and to determine the adequacy of entries documenting the quality of care. HIM professionals are concerned with the used of approved abbreviations, documentation, legibility, and timeliness standards
Quantitative analysis
Review of health record to determine if there are missing reports, forms, or signatures, and correct patient identification.
Concurrent review
A quantitative analysis that is performed while the patient is still in the healthcare facility. Takes place prior to discharge.
Retrospective review
A quantitative analysis that is performed after the patient as has been discharged
Corrections
An edit made in the health record by drawing a single line through erroneous information and writing the word “error” above the mistake. Signature, date and time of correction are required.
Addendum
Provides additional information that was not available at the original time of entry, the addendum must be dated for the day the additional information was added (not the day of the original entry).
Amendment
Clarification made to healthcare documentation after the original document has been signed. The amendment should be dated.timed. and signed the day it was created.
Deficiency slip
Identifies the pertinent document, identifies what needs to be done, and is often created by a computer system.
Form Standards
Strict rules that must be followed when creating forms
Guidelines
Provides a general direction about the design of a form.
Audit trail
A chronological set of computerized records that provides evidence of information system activity used to determine security violations.
Indexing
The linking of patient of patients name, health record number, document type, and other identifying information scanned to a document.
Free-text data
The unstructured narrative data that is the result of a person typing data into an information system.
Natural language processing (NLP)
Technology that coverts human language into data that can be translated then manipulated by computer systems.
Release of Information (ROI)
The process of disclosing patient-identifiable information from the health record to another party.
Abstracting
The process of extracting information from a document to create a brief summary of a patient’s illness, treatment, and outcome. Also, the process of extracting elements of data from a source document or database and entering them into an automated database.
Registry
Database on specific diseases and procedures: cancer and transplant registries are examples
Clinical decision support
Assists physicians and other users when making decisions regarding medications, diagnoses, and such based on information entered into the EHR
Meaningful use
An incentive program for professionals, eligible hospitals, and CAHs participating in Medicare and Medicaid programs to adopt and successfully demonstrate meaningful use through the use of “certified EHR technology”.
Computer assisted coding
The process of extracting data from a the EHR and assigning ICD-10-CM and CPT codes for billing purposes
