Chapters 4-7 Flashcards
Identify the example of administrative information
Patient’s address
The Healthcare Facilities Accreditation Program (HFAP) accredits _________.
All healthcare facilities
Federal and state documentation initiatives as well as the subsequent reimbursement and payment models are now focusing on ____________.
The efficiency, quality, and value of healthcare services provided
What standard must a hospital that participates in the Medicare and Medicaid programs comply with that hospitals who do not accept Medicare and Medicaid patients do not?
Conditions of Participation
Home care records typically include _____.
An individualized treatment plan
Identify the part of a medical history that documents the nature and duration of the symptoms that caused a patient to seek medical attention as stated in that patient’s own words.
Chief complaint
A patient’s registration forms, personal property list, RAI/MDS and care plan and discharge or transfer documentation would be found most frequently in the ___________ health record.
Long-term care
The ___________ is a core component of SNOMED CT.
Concept
The SNOMED CT _________ includes the semantic tag.
Fully specified name
Why are the various types of organizations important to the development of clinical quality measures?
Various parts of the healthcare system have different needs. There is different documentation requirements necessary in different departments.
If data aggregation is the goal of collecting the data, ______ are the best choice.
Classifications
ICD-10-PCS is a classification of _________.
Inpatient procedures
The UHDDS’s core data elements were incorporated into the ___________ prospective payment system.
Acute inpatient
The ___________ is responsible for the publishing and maintaining HCPCS Level II.
CMS
Recommend a concept to create management and oversight of data assets to support the organization’s mission, vision, and values.
Information governance
The evaluation of data collected based on business needs and strategy is part of _______.
Data stewardship
A(n) ___________________ is a list that provides guidance, indication, or other references of information contained in a database?
Index
The healthcare organization needs to create a unique numbering system to identify all forms used within the healthcare organization. It needs to create a _____.
Form tracking system
Identify a collection of data that is organized in a manner to be accessed, managed, reported, and updated electronically.
Database
The capability for two or more electronic systems to communicate and exchange information electronically is known as _____:
Interoperability
_____ includes the process of data governance, patient identification, authorization validation, amendments and record corrections, and audit validation.
Data integrity
The process that focuses on the improving the quality and integrity of patient data while supporting timely coding and reimbursement is known as ________.
Clinical documentation integrity
Identity the database from the National Health Care Survey that uses the patient health record as a data source.
National Ambulatory Medical Care Survey
A _____ is a collection of secondary data related to patients with a specific diagnosis, condition, or procedures.
Disease registry
Integration of biomedical concepts from many sources is performed by _____.
Unified Medical Language System
Identify the index that includes diagnosis code number order of patients discharged from a healthcare organization during a particular time period.
Disease index
To identify the patients who had a craniotomy in the past year, I should query the _____.
Operation index
The medical staff has asked to include benign cancers in the cancer registry. This process is known as _____.
Case definition
Protocols are used in _____.
Clinical trials
In a cancer registry, the accession number _____.
Is the number assigned to each case as it is entered into a cancer registry
