Chapter Two Flashcards
Care Provider
a physician, physicians assistance, dentist, psychologist, nurse practitioner, or midwife, these individuals can diagnose and give orders for diagnostic or therapeutic services
Healthcare professional
generally refers to a nurse, medical assistant, or other technicians who directly cares for the patient
Third-Party Payer
often refereed to as an insurance carrier or company, includes d, Medicaid,Blue Cross/Shield, Tricare, Champva, and any of the private health insurers.
Medical Transcriptionist
healthcare professional who converts the recorded dictation of care providers into typed report form using word processing software
Outguides
in a manual record- keeping system, these are cardboard or plastic folders that take the place of health records and have been removed from file. They include the date the files were removed and the locations to which the files were taken
Electronic Health Record (EHR)
EHR captures more information than an EMR and its designed to be exchanged and used at any point of care, following the patient, EHRS need to meet Meaningful use standards
Electronic Medical Record (EMR)
EMR provides a digital record for the traditional chart used within one location. It does not meet the certification requirements of Meaningful Use because of its limited functionality
Digitized Health Records
health records kept in an electronic binary format
Physician Extenders
providers of healthcare who have advanced education and can diagnose as well as give orders, includes physicians assistant, certified registered nurse anesthetist and nurse midwives.
Quantitative Analysis
the review of a health record to ensure that required documentation is complete and part of the record-for instance- a history and physical report or an operative report-but it does not include a review of the quality of the documentation
Authentication
in a paper record, the signature of the person who wrote an entry in a health record, showing authorship: in a digital environment, the security process of verifying an individual’s right to access a system or portion of it
Delinquent Records
records that remain incomplete after 15-30 Days post discharge or encounter
Medical Staff bylaws
a set of policies that define the code of conduct, categories of medical staff membership, rules and regulations related to individual departments with which they may be affiliated and health information related policies
Document Imaging/scanning
the process of digitizing images of documents into a computer-readable format
Privacy Officer
a higher-level position dealing with compliance with privacy laws, investigation of potential breaches in confidentiality, and monitoring of the facility’s release of information practices
International Classification of Diseases, 9th revision. Clinical Modification (ICD-9-CM)
a classification system used to convert narrative diagnoses and procedures to numeric form for statistical and reimbursement purposes
International Classification of Diseases, 10th revision, Clinical (ICD-10-CM)
a more specific and scalable classification system for coding of diagnoses that, through approved for use in the US, has not yet been implemented at the time of this writing
International Classifcaion of Diseases, 10th revision Procedural Coding System (ICD-10-CM)
a more specific and scalable classification system for coding of inpatient procedures that , through approved for use in the US, has not yet been implemented at the time of this writing
Current Procedural Terminology(CPT)
the coding system used to convert narrative procedures and services performed in an outpatient setting to numeric form
Encoder software
Technology used to assign ICD or CPT codes based on the coder’s input of terms
Grouper Software
Technology used to categorize an inpatient admission or an outpatient encounter into a payment classification
Computer- assisted coding (CAC)
computer software that improves the efficiency and quality of coding by assessing documentation and suggesting possible code choices, which are then verified by the coder
Uniform Hospital Discharge Data Set (UHDDS)
defined data elements that are required to be collected on all hospital discharges
Compliance officer
a position responsible for monitoring activities that are susceptible to fraud, misuse, or overutilizaiton
Revenue Cycle Managers
those responsible for the functions that lead to an efficient effective revenue cycle form the time a patient is registered for care until the bill is paid in full
eHealth managment
the processes and policies that govern the digital collection, maintenance, and archival of data
Enterprise system
a health system made up of a hospital or hospitals, physicians practices,long term care facilities, outpatient(ambulatory) diagnostic and therapeutic facilities, and the like
Information (data) governance
the specification of decision rights and an accountability framework to ensure appropriate behavior in the valuation, creation, storage,use,archiving, and deletion of information: it includes the processes, role and policies, standards, and metrics, the ensure the effective and efficient use of information enabling an organization achieve its goals
Information Security
the administrative, technical, and physical safeguards put in place to ensure the validity and safety of digital data
Cancer Registry
a database of all patients diagnosed or treated for a malignant neoplasm (cancer) in a hospital; the hospital registry data are submitted to a state cancer registry, then reported to the Centers for Disease Control and Prevention (CDC)
Recovery Audit Contractor (RAC)
a position resulting from the Medicare Modernization Act of 2003, with the purpose of recovering improper Medicare payments
Voice Recognition
software that recognizes the dictation of care provider or other professional and converts the speech to text
Commission on Accreditation for Health Informatics and Information Management Education (CAHIIM)
an independent accrediting organization whose mission is to serve the public interest by establishing and enforcing quality Accreditation Standards for Health informatics and Health Information Management (HIM,2014) educational programs (CAHIIM,2014)
