Chapter 6 Key Terms

Question 1

Transcription system

Answer 1

used by the transcriptionist to type the various documents dictated by physicians

Question 2

trauma registry software

Answer 2

an information system that tracks patients with traumatic injuries from initial trauma to death

Question 3

rules-based encoder

Answer 3

an encoder that requires the user type in the name or portion of the name of the diagnosis or procedure. This entry into the encoder generates a list of suggestions from which the coder selects.

Question 4

ROI system

Answer 4

A valuable tool designed to manage the processing of requests for protected health information (PHI) received and process by the HIM department

Question 5

Natural language processing

Answer 5

NLP: a technology that converts human language (structure or unstructured) into data that can be translated then manipulated by information systems.

Question 6

Healthcare quality indicator system

Answer 6

an abstracting system that records information about the patient, the care provided to the patient, and the healthcare practitioner(s) involved in the care delivered

Question 7

Health informatics

Answer 7

the scientific discipline that is concerned with the cognitive, information-processing, and communication tasks of healthcare practice, education, and research, including the information science and technology to support these tasks

Question 8

Grouper

Answer 8

a computer program that uses specific data elements to assign the diagnostic and procedural codes entered into the encoder into the appropriate MS-DRG or other DRG.

Question 9

Expander

Answer 9

allows transcriptions to type an acronym that will have the full phrase automatically spelled out

Question 10

Encoder

Answer 10

specialty software used by coders to select appropriate codes for the diagnosis(es) and procedure(s) supported by the health record

Question 11

dictation system

Answer 11

used by physicians to dictate various medical reports

Question 12

computer-assisted coding sytem

Answer 12

CAC system: analyzes the clinical data found int he EHR. CAC is the process of extracting and translated dictated and then transcribed free-text data (or dictated and then computer-generated discrete data) into codes for billing and coding purposes.

Question 13

clinical documentation improvement system

Answer 13

CDI system: assists in identifying ways to improve clinical documentation in the health record.

Question 14

chart tracking system

Answer 14

also called the chart locator system, is designed to identify the current location of the paper health record

Question 15

chart locator system

Answer 15

also called the chart tracking system, is designed to identify the current location of the paper health record

Question 16

chart deficiency system

Answer 16

records and tracks when a medical record comes to an HIM department with a documentation omission

Question 17

cancer registry information system

Answer 17

tracks information about the patient’s cancer from the time of diagnosis to the patient’s death

Question 18

birth certificate information system

Answer 18

state-approved system in which the birth certificate data are entered after the HIM staff interviews the mother or other patients/guardians and reviews the health record. It reports births in the facility to the state health agency.

Question 19

automated codebook encoder

Answer 19

an encoder that lists diagnoses and procedures in alphabetic order much like the alphabetic index

Question 20

logic-based encoder

Answer 20

prompts the coder by asking a variety of questions after entering the code and the most appropriate code is narrowed down as a result.