Definitions Flashcards
Affordable Care Act
Mandates comprehensive health insurance reform (e..g, prohibits denial of coverage based on pre-existing conditions)
Authorization
Required for release of patient PHI
CMS
Centers for Medicare and Medicaid Services - Federal Agency charged with administration of the Medicare and Medicaid programs
CCHIT
Certification Commission of Health Information Technology - Established to evaluate and approve EHR and EMR systems
Computer on Wheels
COW - Most often refers to a laptop computer on a cart with wheels rolled between patient rooms
CPOE
Computerized Provider Order Entry - Allows providers to order prescription medications, including IV therapies, lab tests, imaging studies, rehab services, dietary requirements in the inpatient environment
CCD
Continuity of Care Document - Federally-mandated document that acts as a standardized patient summary, facilitating the sharing of patient health information across facilities
Credentialing
Process used to document a provider’s education, licensure, and qualifications in order to allow for the assignment of privileges so they can practice in a health care system
CPT
Current Procedural Terminology - Naming system the AMA (American Medical Association) publishes and maintains, allowing providers to code for services provided
Discharge summary
Report written by provider when patient is being discharged from inpatient care; summarizes why patient was admitted, diagnostic test results, treatments administered, and how patient responded to them
EHR
Electronic Health Record. A record that involves inputs from many systems and is used across a diverse environment of care with multiple locations
EMR
Electronic Medical Record - Generic terms for digitized medical record. Term has evolved to most often refer to the single, standalone records systems that providers’ offices and outpatient settings use
ePrescribing
Functionality that allows providers to prescribe medications to patients and send the prescription to the patient’s pharmacy.
HIM Department
Health Information Management Department - Responsible for the care and management of all patient info
HIPPA
Health Insurance Portability and Accountability Act - Legislation that protects employees’ insurance coverage when they are between jobs. Title II established standards that apply to electronic transactions involvinv health care data
HIPPA Privacy Rule
Mandates the protection of patients’ personal health information by hospitals and facilities, specifically around what information can be shared and who it can be shared with
HIPPA Security Rule
Sets forth administrative, physical, and technical safeguards for covered entities in order to protect the PHI that is stored electronically
HIS
Hospital Information System - Collection of systems that collect, store, and manage data generated in daily facility operations
ICD-9-CM
International Classification of Diseases, 9th Revision, Clinical Modification - Coding and classification system that groups diseases, disorders, and procedures into similar categories. Has 3 volumes.
MPI
Master Patient Index - Record of every patient who has been treated, seen, or evaluated in a facility. Must be forever maintained and cannot be purged or destroyed after time
Meaningful Use
Both a program and definition. Program refers to the federal incentives established by CMS for facilities to use EHR tech in a meaningful way. The definition refers to using EHR tech in a manner that makes a meaningful impact on patient care and safety
PHI
Protected Health Information - info that can individually identify a person like demographic data or a common identifier like SSN, DOB, address, phone number, etc…
ROI
Release of information
RBACs
Role-Based Access Controls - Control the ability to access certain areas of the system, associated with their login information
CPT Codes
Current Procedural Terminology codes - Numeric codes developed by the American Medical Association to standardize medical services and procedures
Encounter Form
A form the provider fills out as they see the patient. It lists the service charges and how much the patient paid for the services. Can be submitted for billing
Face Sheet
Standard structured document that contains patient info like name DOB, insurance info, reason for seeking care, and religious preference.
HCPCS
Healthcare Common Procedure Coding System - Numeric and alphabetic coding system used for billing and pricing of procedures, medical supplies, medications, and durable medical equipment
ICD-9-CM codes
International Classification of Diseases, Ninth Revision, Clinical Modification codes - Alphanumeric codes used to classify injuries, diseases, symptoms, and cause of death
Insurance verification
Process used to make sure the service received by the patient is approved and paid for by the insurance company
NPI number
National provider identifier number - Unique 10-digit number assigned to providers in US
Practice management system
Software designed to assist in office workflow by streamlining scheduling, insurance info, billing, etc..
Ad hoc reports
Reports created in response to an inquiry that comes up. Not normally scheduled reports
GIGO
Garbage-in, garbage-out - Refers to fact that poor documentation entry results in poor output from a computer system
Incomplete charts
Charts missing signatures, reports, or other elements
POC charting
Point-of-care charting - Ability of providers to document the treatment they render in real time when they are with the patient
Upcoding
Intentional or unintentional assignment of a higher level code than documentation supports
Addendum
Additional documentation added to a health record that represents new data not included in the original documentation. Adding new information
Advance directives
Documents that give patients the right to make decisions about their care and designate others to make decisions if they are incapacitated
Amendment
An addition to patient record documentation meant to clarify or further explain existing record information. Expanding on existing information.
Audit trails
A computer software program that tracks users by login and documents where they users go and which applications they access
Compliance Officers
A health care administrator charged with overseeing all compliance activities in the facility.
Corrections
Entries in a patient health record that correct or change original data
De-identify
The stripping of any identifying pieces of data from health records so they can be used in research
Late entries
Documentation added to the patient record after the care was provided
Minimum necessary standard
The HIPPA standard that requires covered entities to release only the minimum amount of patient health data to meet the need of the request
PSDA
Patient Self-Determination Act. Legislation that gives patients the right to make decisions about their care and outcomes, including being left alone to die and not resuscitated
Privacy Official
HIPPA-required individual who is the point person for any privacy concerns or complaints
Accounts receivable
Patient bills for services that have already been provided that legally are due to a facility
Autopsy rates
The percent of autopsies performed on patients who die in the hospital. Sometimes legal inquiry or family preference prevent them
ALOS
Average length of stay. Total inpatient days divided by number of discharges (or admissions)
Benchmarks
Goals the facility wants to meet. Typically an external benchmark based on industry standards
CDC
Centers for Disease Control and Prevention
Comorbidity
Separate disease that exists at the same time as a primary disease that a patient is being treated for at that time
Daily census
The count of how many patients are in beds by patient care unit for an inpatient facility
HHS
Department of Health and Human Services
IOM
Institute of Medicine
Morbidity
Refers to disease
Mortality (death) rate
Percentage of all discharged patients who are discharged due to death within a prescribed period
National Hospital Inpatient Quality Measures
Set of specific data that hospitals must collect and report to CMS and the Joint Commission to document quality and patient care
Occupancy rate
Percentage of licensed beds in a hospital that have a patient in them
PCU
Patient care unit. For the purpose of census data, a PCU has a defined number of beds and is staff assigned; also called floors, units, or wards
Total inpatient service days
The number of inpatients receiving care each day summed for the days in the period under study
