Final Review

Question 1

T.O.

Answer 1

Telephone Order

Question 2

DAT

Answer 2

Diet As Tolerated

Question 3

ROS

Answer 3

Review of Systems

Question 4

Lap Chole

Answer 4

Laparoscopic Cholecystectomy

Question 5

COPD

Answer 5

Chronic Obstructive Pulmonary Disease

Question 6

TKA

Answer 6

Total Knee Arthroplasty

Question 7

DC IV

Answer 7

Discontinue IV

Question 8

WNL

Answer 8

Within Normal Limits

Question 9

DX

Answer 9

Diagnosis

Question 10

HX

Answer 10

History

Question 11

Registry

Answer 11

An organized system for the collection, storage, retrieval, analysis, and dissemination of individuals who have either a particular illness or condition that predisposes them to the occurrence of a health related event or prior exposure to substances or circumstances known or suspected to cause adverse side effects.

Question 12

Negligence

Answer 12

Failure to exercise the degree if care considered reasonable under the circumstances, resulting in an unintended injury to another party.

Question 13

The National Center for Health Statistics (NCHS)

Answer 13

The federal agency responsible for maintaining official vital statistics.

Question 14

Case-Mix Analysis

Answer 14

The study of the types of patients treated by the facility.

Question 15

Descriptive Statistics

Answer 15

Summarizing a set of data using charts, graphs, and tables.

Question 16

Daily Census Count

Answer 16

Number of inpatients present at census taking time (usually midnight).

Question 17

Chargemaster

Answer 17

Document that lists all the procedures, services, and supplies provided to patients by a hospital or from patients to a hospital.

Question 18

Discovery

Answer 18

The legal process lawyers use to obtain information about all aspects of a case.

Question 19

Average Length of Stay (LOS)

Answer 19

Divide the total LOS by the number of patients discharged.

Question 20

Index

Answer 20

A guide to point out, or otherwise facilitate references, of names, places, and subjects, giving the page or pages on which items is located.

Question 21

Severity of Illness

Answer 21

The physiologic complexity that comprises the extent and interactions of a patient’s disease(s) as presented to medical professionals.

Question 22

Register

Answer 22

A formal or official recording of items, names, or actions.

Question 23

Interrogatory

Answer 23

A form of discussion that includes a list of written questions that must be answered by the party served.

Question 24

Contempt of Court

Answer 24

Failure to obey a subpoena which is punishable by fine or imprisonment.

Question 25

Malpractice

Answer 25

When a healthcare provider acts in an improper or negligent manner and the patient’s result is injury, damage, or loss.

Question 26

Data Integrity

Answer 26

If data is accurate, complete, consistent, up to date, and the same no matter where the data is recorded.

Question 27

Subpoena Duces Tecum

Answer 27

Written command or direction, signed by the clerk of court, ordering an individual to appear in court with documents. (Ex. medical records)

Question 28

Privileged Communication

Answer 28

Any information communicated by a patient to a health care provider.

Question 29

Protected Health Information (PHI)

Answer 29

Information that is identifiable to an individual such as name, address, telephone numbers, date of birth, medicaid id number, MR #, SS #, name of employer, etc.

Question 30

Conditions of Participation (CoP)

Answer 30

Federal Regulations that health care organizations must meet in order to participate in the Medicare or Medicaid programs.

Question 31

Case Abstracting

Answer 31

An automated or manual process performed for health information department staff to collect patient information to determine prospective payment system status, generate indexes, and report data to quality improvement organizations and state and federal agencies.

Question 32

Medial Nomenclatuer

Answer 32

Vocabulary of Clinical and Medical Terms

Question 33

Data Validity

Answer 33

If data conforms to an expected range of values

Question 34

Clearinghouse

Answer 34

A public or private entity that processes or facilitates the processing of health information received from another entity from a non standard to a standard format.

Question 35

Data Mining

Answer 35

Using software to search for patients, trends, and to produce data content relationships.