Chapter 4: Vocabulary Flashcards
To assist you in learning the vocabulary found throughout your text, the exam, and the industry.
Accreditation
A voluntary process institutional or organized review in which a quasi-independent body created for this purpose peridoically evaluates the quality of the entity’s work against preestablished written criteria. 2. A determination by accrediting body that an eligible organization, network, program, group, or individual complies with applicable standards. 3. The act of granting approval to a healthcare organization based on whether the organization has met a set of voluntary standards developed by and accreditation agency.
Accreditation organizations
A professional organization that established the standards against which healthcare organizations are measured and conducts periodic assessments of the performances of individual healthcare organizations.
Acknowledgments
a form that provides a mechanism for the resident to recognise receipt of important information.
Administrative data
Coded information contained in secondary records, such as billing records, describing patient indentification, diagnoses, procedures, and insurance.
Ambulatory
Treatment provided on an outpatient basis.
Ambulatory surgery center/ambulatory surgical center (ASC)
Under Medicare, an outpatient surgical facility that has own national identifier; is a seperate entity with respect to its liscensure, accreditation, governance, professional supervision, administrative functions, clinical services, recordkeeping, and financial and accounting systems; has as its sole purpose the provision of services in connection with surgical procedures that do not require inpatient hospitalization; and meets the conditions and requirements set forth in the Medicare Conditions of Participation.
American Association for Accreditation of Ambulatory Surgery Facilities (AAAASF)
An organization that provides an accreditation program to ensure the quality and safety of medical and surgical care provided in ambulatory surgery facilities.
Ancillary services
- Tests and procedures ordered by a physician to provide information for use in patient diagnosis or treatment 2. Professional healthcare services such as radiology, laboratory, or physical therapy.
Anesthesia report
The report that notes any preoperative medication and response to it, the anesthesia administered with dose and method of administration, the duration of administration, the patient’s vital signs while under anesthesia, and any additional products given the p patient during a procedure.
Authentication
- The process of identifying the source of health record entries by attaching a handwritten signature, the author’s initials, or an electronic signature. 2. Proof of authorship that ensures, as much as possible, that log-ins and messages from a user originate from an authorized source. 3. As amended by HITECH, means the corroboration that a person is the one claimed.
Authorization
- As amended by HITECH, except as otherwise specified, a covered entity may not use or disclose protected health information without an authorization that is valid under section 164.508 2. When a covered entity obtains or receives a valid authorization for its use or disclosure or protected health information, such use or disclosure must be consistent with the authorization.
Auto-authentication
- A procedure that allows dictated reports to be considered automatically signed unless the health information management department is notified of needed revisions within a certain time limit. 2. A process by which the failure of an author to review and affirmatively either approve or disapprove an entry within a specified time periods results in authentication.
Autopsy report
Written documentation of the findings from a postmortem pathological examination.
Care area assessments (CAAs)
The patient is assessed and reassessed at defined intervals as well as whenever there is significant change in his or her condition.
Care plan
The specific goals in the treatment of an individual patient, amended as the patient’s condition requires, and the assessment of the outcomes of care; serves as the primary source for ongoing documentation of the resident’s care, condition, and needs.
Center for Medicare and Medicaid Services (CMS)
The federal agency within the US Department of Health and Human Services.
Certification
- The process by which a duly authorized body evaluates and recognizes and individual, institution, or educational program as meeting predetermined requirements 2. An evaluation performed to establish the extent to which a particular computer system, network design, or application implementation meets a prespecified set of requirements.
Clinical data
The information that reflects the treatment and services provided to the patient as well as how the patient responded to such treatment and services
Clinical observations
The observations of physicians, nurses, and other caregivers i order to create a chronological report of the patient’s condition and reponse to treatment during his or her hospital stay.
Commission for the Accreditation of Rehabilitation Facilities (CARF)
An international, independent, nonprofit accreditor of health and human services that develops customer-foucsed standards for areas such as behavioral healthcare, aging services, child programs and accredits such programs on the basis of its standards.
Conditions for Coverage
Standards applied to facilities that choose to participate in federal government reimbursemet programs such as Medicare and Medicaid.
Conditions for Participation
The administrative (policy and provedure requirements) and operational guidelines (how the polocies and procedures are carried out) under which facilities are allowed to take part in the Medicare and Medicaid programs.
Consent to treatment
Legal permission given by a patient or a patient’s legal representative to healthcare provider that allows the provider to administer care and treatment or to perform sugery or other medical procedures.
