Health Data Content and Standards Flashcards
In an accession number (ex: 12-0001/00), what does the 12 represent?
The year the patient first entered the database.
In an accession number (ex: 12-0001/00), what does the 0001 indicate?
The case number for the year.
In an accession number (ex: 12-0001/00), what does the 00 indicate?
the number of known neoplasms (00 means one known neoplasm).
What is Meaningful Use?
Term used in the ARRA/HITECH legislation for providers to qualify for incentives for using EHR.
What are the three requirements for Meaningful Use?
Use of certified EHR technology in a meaningful manner. The EHR provides an electronic exchange of health information. By using the EHR, the provider submits information on clinical quality measures.
What is the OASIS Data Set?
Outcomes and Assessment Information Set. A standard core assessment data tool developed to measure the outcomes of adult patients receiving home health services under Medicare and Medicaid.
What is the DEEDS Data Set?
Data Elements for Emergency Department Systems. A data set designed to support the uniform collection of information in hospital-based emergency departments.
What resource is used to determine certification standards for CMS?
Federal Register.
What is an Electronic Document Management System?
A storage solution based on digital scanning technology in which source documents are scanned to create digital images of the documents that can be stored electronically on optical disks.
What is an Expert System?
A type of information system that supports the work of professionals engaged in the development or evaluation of complex activities that require high-level knowledge in a well-defined and usually limited area.
What is Computerized Provider Order Entry?
Systems that allow physicians to enter medication or other orders and receive clinical advice about drug dosages, contradictions, or other clinical decision support.
What is a Regional Health Information Organization?
A health information organization that brings together healthcare stakeholders within a defined geographic area and governs health information exchange among them.
The time period for completion of the H & P in the medical record is how long?
24 hours after admission or prior to surgery.
What is Utilization Review?
The process of determining whether the medical care provided to a specific patient is necessary according to pre-established objective screening criteria at time frames specified in the management plan.
What is Quantitative Review/Analysis?
A review of the health record to determine its completeness and accuracy.
