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AHS 435 > EXAM 1 > Flashcards

EXAM 1 Flashcards

1
Q

What is the definition of health information according to HIPPA?

A

any information, whether oral or recorded in any form or medium, that is created or recieved by a health care provider, health plan, public authority, employer, insurer, school or healthcare clearinghouse and relates to past, present, of future condition of an individual

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2
Q

According to HIPPA what determines if it is PHI?

A

information must first of all be identifiable, that is, it must have an individual patient perspective and the patient’s identity must be known

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3
Q

EMR

A

used within an organization

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4
Q

EHR

A

used across multiple organizations

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5
Q

PHR

A

controlled by individual

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6
Q

EMR vs EHR

A

EHR conforms to nationally recognized interoperability standards and can be used by multiple sources

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7
Q

Patient Care

A

basis for planning patient care and treatment, number one reason for maintaining records

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8
Q

Communiction

A

allows dr’s, nurses, and others to communicate about patient needs

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9
Q

Legal documentation

A

describe and document care and treatment

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10
Q

Billing and reimbursement

A

provide the documentation patients and payers use to verify billed services

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11
Q

Research and qualitity management

A

research purposes and for monitoring the qualitiy of care provided

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12
Q

Population Health

A

used to monitor population health, assess heath status, measure utlilization of services, track qualitiy outcomes, and evaluate adherence to evidence based practice guidelines

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13
Q

ID Sheet

A

1st sheet or screen, patient name, address, phone #, insurance info, and policy #, as well as patient’s diagnoses adn disposition at discharge

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14
Q

Problem List

A

lists significant illnesses and operations, maintained overtime

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15
Q

Medication Record

A

leist medicines prescribed for and subsequently administered to the patient, includes allergies

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16
Q

History and Physical

A

describes any major illnesses and surgeries the patient has had, familiy history of disease, patient health status, and current medications

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17
Q

Progress notes

A

made by physicians, nurses, therapists, social workers, and other clinical staff caring for the patient

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18
Q

Consultation

A

NOTE or report records opions about patients condition made by a health care provider other than the attending

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19
Q

Physician Orders

A

instructions or prescriptions given to other members of the health care team by the physician

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20
Q

Imaging reports

A

not typically part of patient record but must be maintained at same level

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21
Q

Lab reports

A

results of test conducted on body fluids, cells, and tissues

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22
Q

Content and authorization forms

A

copies of consents ot admission, treatment, surgery and release of information

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23
Q

Operative report

A

describes surgery performed and list names of surgeons and assistants

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24
Q

Pathology report

A

describe tissue removed during any surgical procedure and diagnosis based on examination of that tissue

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25
Q

Discharge summary

A

summurazies the hospital stay

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26
Q

Source-oriented medical record

A

organized by the source of the information

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27
Q

POMR(patient-oriented medical record)

A

organized around the patients problems, contains database and problem list

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28
Q

UB-04

A

de facto hospital and other institution claim standard, required by federal and state governments in their role as third-party payers, also adopted by private US third-party payers

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29
Q

CMS-1500

A

de facto standard for all types of noninstitutional providers claims, such as physician services

30
Q

Uniform data sets

A

data can be compared not only within organizations but within states and across the country

31
Q

UHDDS

A

Uniform Hospital Discharge Data Set definitions are the standard for Medicare and Medicaid programs

32
Q

ACDS

A

Uniform Ambulatory Data Set, the goal is to improve the data collected in ambulatory and outpatient settings, recommended rather than a required data set

33
Q

MDS

A

Minimum Data Set, used for long term care is federally mandated standard assessment tool that is used to collect demographic and clinical information about long term care facility residents

34
Q

What are the two major coding systems utilized today and how are they utilized?

A

ICD-10-code disease information, CPT provides uniform language for describing medical and surgical services

35
Q

When is ICD-10-CM/PCS being implemented?

A

October 2014

36
Q

Benchmarking

A

The process of comparing one or more outcome measures against a standard

37
Q

Balanced Scorecards

A

meets executives need to design measurement systems aligned with their organizational goals, examines multiple measures

38
Q

Health Plans

A

NCQA (National Committee for Quality Assuurance) accreditation and quality assurance develop the HEDIS(Health Plan Employer Data and Information Set) which consist of 76 measures across five domains of care and is used by over 90% of America’s health plans

39
Q

Cliniccal Indicators

A

The Joint Commission Quality Check provides performance measures and acreditadation status & CMS indicatior are aimed at hospitals, nursing homes, home care, and physicians practices reports provide info on process of care measures, outcome of care measures, use of medical imaging, surveying of patients’ hospital experiences, safety measures and medical payment information

40
Q

Population Measures

A

CDC:& AHRQ: collect statewide morbidity and mortality data

41
Q

Information

A

information is processed data

42
Q

Data

A

raw health care facts that describe particular events

43
Q

Knowledge

A

combination of rules, relationships, ideas, and experience. information applied rules, experiences, and relationships used to decisions

44
Q

Markle’s Five

A

Affects the quality of care
Introduces privacy and other civil liberty concerns
Increases costs and inefficiencies
Creates liability risks
Undermines the reliability and benefits of (IT) investments

45
Q

Poor quality data originates from what two areas

A

content and form

46
Q

Medical Records Institute 5 major functions negatively affected by poor quality

A
  1. Patient Safety
  2. Public Safety
  3. Continuity of Care
  4. Health care economics
  5. Clinical research and outcome analysis
47
Q

Information Capture

A

process of recording represtations of human thought, perceptions, or actionsin documenting patient care, as well as device-generated information that is gathered about a patient as a part of health care

48
Q

Report Generation

A

process of analyzing, organizing, and presenting recorded patient information for authentication and inclusion in the documentation resulting in high-quality data, both information capture and report generation must be considered

49
Q

Key principles developed by the MRI that should be adhered to

A

Unique patient ID, must be asseured w/n and a/c healthcare documentation systems
Documentation must be: accurate & consistent, complete, timely, interoperabel a/c types of documentation systems, Accessible at any time and place, Auditable
Confidential and secure authentication and accountability must be provided

50
Q

Data accuracy

A

reflect correct, valid values are accurate

51
Q

Accessibility

A

data that are not available to the decision makers needing them are of no use

52
Q

Comprehensiveness

A

all of the data required for a particular use must be present and available to the user

53
Q

Consistency

A

Quality data are consistent

54
Q

Currency

A

Many types of health care data b/c obsolete after a period of time, admitting and discharge diagnosis often differ

55
Q

Definition

A

clear definitions of data elements must be provided so that both current and future data users will understand what the data mean

56
Q

Grandularity

A

individual data are atomic in that they cannot be further divided

57
Q

Percision

A

relates ot he numerical data, denotes how close to an actual size, weight, or other standard a particular measurement is

58
Q

Relevancy

A

must be relevant to the purpose for which they are collected

59
Q

Timeliness

A

a critical dimension inthe quality of health care data

60
Q

AHIMA data quality model: application, collection, warehousing, analysis

A

Application: the purpose for which data is collected
Collection: the processes by which data elements are accumulated
Warehousing: processing & systems used to archive data and data journals
Analysis: process of translating data information utilized for an application

61
Q

Systematic errors:

A

can be attributed to a flaw or discrepency in adherence to standard operating procedures or systems

62
Q

Random errors:

A

Carlessness rather than lack of training leads to random errors

63
Q

Data prevention

A

compose a minimum set of necesary data items
define data and data characteristics in a data dictionary
develop a data collection protocol
user friendly interface
data checks
QA
train and motivate

64
Q

Data Detection

A

Perform automatic data checks
Perform data quality audits
Review data collection protocols and procedures
Check interand intraobserver variability
inspect completed forms
Reoutinely check completeness of data entry

65
Q

Improvement

A

Provide quality reports to users
correct inaccurate data and fill in incomplete data detected
Control user correction of data errors
Give feedback of data quality results adn recommedations
Resolve identified causes of data errors
Implement identified system changes
Communicate with users

66
Q

unstructured data

A

refers to information that either does not have a pre-defined data model

67
Q

structured data

A

data that resides in a fixed field within a record

68
Q

Facility licensure

A

gives facility legal approval to operate and each state sets its own licensure laws and regulations

69
Q

Certification

A

gives athority to participate in federal Medicare and Medicaid programs

70
Q

Accreditation

A

external review process that organizations elects to go undergo, can lead ot deemed status for CMS programs, is recognized by many states as licensure requirements

71
Q

Deemed Status

A

inorder to participate in and recieve payments form CMS, it must be certified as complying with Conditions of Participation

AHS 435 (1 decks)

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