Chapter 3: Vocabulary

Question 1

Health record

Answer 1

Contains information relating to the physical or mental health or condition on an individual.

Question 2

Data

Answer 2

Raw facts. Data are individual facts, statistics, or items of information collected together for reference or analysis

Question 3

Information

Answer 3

Data that has been turned into something meaningful

Question 4

Hybrid health record

Answer 4

A combination of a paper record and the EHR

Question 5

Aggregated data

Answer 5

Data that has been extracted from the individual health record and combined to form deidentified information about a group of patients.

Question 6

Master patient index (MPI)

Answer 6

The permanent record of all patients treated at a healthcare facility

Question 7

Demographics

Answer 7

Basic information about the patient such as their name, DOB, address, and insurance information

Question 8

Duplicate health record

Answer 8

A patient has two or more health record numbers in the same facility.

Question 9

Overlay

Answer 9

A patient was assigned someone else’s health record number

Question 10

Overlap

Answer 10

A patient has more than one health record number at different locations within the same enterprise

Question 11

Algorithms

Answer 11

Used to maintain quality control in the MPI by reducing duplicates, overlays, and overlaps through matching patients so that patient information can be merged.

Question 12

Deterministic algorithm

Answer 12

Requires an exact match of data elements

Question 13

Probabilistic algorithm

Answer 13

Uses mathematical probabilities to determine the possibility that two patients are the same.

Question 14

Rules-based algorithm

Answer 14

Assigns a weight to specific data elements and uses those weights to compare one record to another.

Question 15

Serial numbering system

Answer 15

A patient is issued a unique numerical identifier for every encounter at the healthcare facility

Question 16

Unit numbering system

Answer 16

A patient is issued a unique health record number during the first encounter and that number is used for all subsequent encounters

Question 17

Serial-unit numbering systems

Answer 17

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.

Question 18

Qualitative analysis

Answer 18

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

Question 19

Quantitative analysis

Answer 19

Review of health record to determine if there are missing reports, forms, or signatures, and correct patient identification.

Question 20

Concurrent review

Answer 20

A quantitative analysis that is performed while the patient is still in the healthcare facility. Takes place prior to discharge.

Question 21

Retrospective review

Answer 21

A quantitative analysis that is performed after the patient as has been discharged

Question 22

Corrections

Answer 22

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.

Question 23

Addendum

Answer 23

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).

Question 24

Amendment

Answer 24

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.

Question 25

Deficiency slip

Answer 25

Identifies the pertinent document, identifies what needs to be done, and is often created by a computer system.

Question 26

Form Standards

Answer 26

Strict rules that must be followed when creating forms

Question 27

Guidelines

Answer 27

Provides a general direction about the design of a form.

Question 28

Audit trail

Answer 28

A chronological set of computerized records that provides evidence of information system activity used to determine security violations.

Question 29

Indexing

Answer 29

The linking of patient of patients name, health record number, document type, and other identifying information scanned to a document.

Question 30

Free-text data

Answer 30

The unstructured narrative data that is the result of a person typing data into an information system.

Question 31

Natural language processing (NLP)

Answer 31

Technology that coverts human language into data that can be translated then manipulated by computer systems.

Question 32

Release of Information (ROI)

Answer 32

The process of disclosing patient-identifiable information from the health record to another party.

Question 33

Abstracting

Answer 33

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.

Question 34

Registry

Answer 34

Database on specific diseases and procedures: cancer and transplant registries are examples

Question 35

Clinical decision support

Answer 35

Assists physicians and other users when making decisions regarding medications, diagnoses, and such based on information entered into the EHR

Question 36

Meaningful use

Answer 36

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”.

Question 37

Computer assisted coding

Answer 37

The process of extracting data from a the EHR and assigning ICD-10-CM and CPT codes for billing purposes