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Health Care Information > Mid Term > Flashcards

Mid Term Flashcards

0
Q

HIM was recognized as a allies health profession in

A

1928

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1
Q

AHIMA’s primary fx is

A

To promote accuracy, confidentiality and accessibility of health records.

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2
Q

What is CoP?

A

A virtual network of AHIMA members for communicating via web based program through a AHIMA. Is only open to members and provides contact for quick problem-solving and support

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3
Q

What is CPT?

A

Current procedural terminology in. Are used to report physician services to the Medicare program to determine reimbursement

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4
Q

What is DSM-IV-TR?

A

American psychiatric Association diagnostic and statistical manual of mental disorders. Glossary of mental disorders

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5
Q

What is HCPCS?

A

Healthcare common procedure coding system. Collection of codes and descriptions used to represent healthcare procedures supplies products and services

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6
Q

ICD-9-CM

A

International classification of diseases, 9th revision clinical modification. Value one top your list, numerical code to represent diseases and injuries. Volume two alphabetical list for all codes and volume one. Volume three only use the US

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7
Q

ICD-10-CM

A

International classification of diseases 10th revision clinical modification

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8
Q

ICD-O

A

International classification of diseases for oncology; developed to aid in the collection of information in the field of oncology

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9
Q

SNOMED-CT

A

Systemized nomenclature of medical clinical terminology; is a systemized multi axial and hierarchaly organized nomenclature of medically useful terms

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10
Q

Accreditation

A

Voluntary process of institutional or organizational review in which a quasi-independent body created for this purpose periodically evaluates the quality of the entities work against Preestablished written criteria

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11
Q

Data relevancy

A

Data are useful (quality characteristic)

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12
Q

Data granularity

A

Attributes and values of data defined at correct level of detail for intended use

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13
Q

Data precision

A

Term used describe expected data values

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14
Q

Comorbidity

A

A medical condition that coexist with the primary cause for hospitalization and affects the treatment length of stay

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15
Q

Complication

A

A medical condition that arises during an inpatient hospitalization

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16
Q

POA

A

Present on admission, a condition present at the time of in patient admission

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17
Q

Principal diagnosis

A

The disease or condition that was present on admission, was a principal reason for admission, and receive treatment or evaluation during the hospital stay or visit

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18
Q

Case mix index

A

The average weight of all cases treated at a given facility or by a given position which reflects the resource intensity or clinical severity of a specific group in relation to the groups in the classification system

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19
Q

Source orientated health record

A

Organizes the patient info according to the patient care department that provided the care, grouped together according to their point of origin

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20
Q

Problem orientated records

A

Documentation approach where the physician defines each clinical problem individually and then organizes it into a database problem list. each problem is indexed with a unique number

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21
Q

Integrated orientated health record

A

Organizes all paper forms in strict chronological order and mixes the forms created by different departments. Easy to follow up course of patient’s treatment but is difficult to compare a similar types of information due to format

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22
Q

Integrated record

A

Progress notes of physicians, nurses, therapist and other authorized individuals will be found together in chronological sequence

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23
Q

OASIS

A

A standard for assessment data tool developed to measure the outcomes of patients receiving home health services under the Medicare and Medicaid programs

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24
Q

Point of care charting

A

Provide context sensitive templates that ensure that the appropriate data are collected and guide users to adhering to professional practice standards

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25
Q

Computerized provider OE

A

Physicians use this for drugs diagnostic studies

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26
Q

UHDDS

A

Uniform hospital discharge date is set. List defines a set of common uniform data elements, used in hospitals

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27
Q

UACDS

A

Uniform ambulatory care data set, includes medical and surgical care provided to patient to depart from the facility on the same day they receive care. Physicians offices medical clinics same-day surgery centers, outpatient hospital clinic and diagnostic departments

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28
Q

MDS

A

Minimum data set, long-term care Medicaid and Medicare services

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29
Q

DEEDS

A

Data elements for emergency departments

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30
Q

HEDIS

A

Health plan employer data and information sets, population-based data

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31
Q

TJC

A

The joint commission. Conducts accreditation service and more than 17,000 healthcare organizations including ambulatory care facilities long-term care facilities behavioral health facilities healthcare networks, MCO’s and acute care hospitals

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32
Q

Not for profit hospital

A

Use excess funds to improve their services and to find his education programs and community services

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33
Q

For-profit hospitals

A

Privately owned excess funds are paid back to the managers, owners and investors and form of bonuses and dividends

34
Q

Voluntary hospitals

A

Not for profit on by and universities, churches, religious orders, unions and other not-for-profit entity

35
Q

Morbidity

A

The number of sick person’s or cases of disease in relationship to a specific population

36
Q

Mortality

A

Incidence of death in a specific population

37
Q

Integrated healthcare delivery system

A

Healthcare provider made up of a number of associated medical facilities that furnish coordinated healthcare services. purpose is to organize continuum of care, maximize effectiveness and reduce costs

38
Q

Medical history

A

Patient’s current complaints and symptoms and list his or her past medical personal and family history

39
Q

Physical exam

A

Position Sussman of the patient’s current health status. HEENT

40
Q

EDI

A

Electronic data interchange. the discrete data from the prescription go directly to the pharmacies information system

41
Q

SOAP notes

A

S=subjective, patients words o=objective data, factual, lab results A=assessment P=plans, what going to do

42
Q

To promote accuracy, confidentiality and accessibility of health records.

A

AHIMA’s primary fx is

43
Q

1928

A

HIM was recognized as a allies health profession in

44
Q

A virtual network of AHIMA members for communicating via web based program through a AHIMA. Is only open to members and provides contact for quick problem-solving and support

A

What is CoP?

45
Q

Current procedural terminology in. Are used to report physician services to the Medicare program to determine reimbursement

A

What is CPT?

46
Q

American psychiatric Association diagnostic and statistical manual of mental disorders. Glossary of mental disorders

A

What is DSM-IV-TR?

47
Q

Healthcare common procedure coding system. Collection of codes and descriptions used to represent healthcare procedures supplies products and services

A

What is HCPCS?

48
Q

International classification of diseases, 9th revision clinical modification. Value one top your list, numerical code to represent diseases and injuries. Volume two alphabetical list for all codes and volume one. Volume three only use the US

A

ICD-9-CM

49
Q

International classification of diseases 10th revision clinical modification

A

ICD-10-CM

50
Q

International classification of diseases for oncology; developed to aid in the collection of information in the field of oncology

A

ICD-O

51
Q

Systemized nomenclature of medical clinical terminology; is a systemized multi axial and hierarchaly organized nomenclature of medically useful terms

A

SNOMED-CT

52
Q

Voluntary process of institutional or organizational review in which a quasi-independent body created for this purpose periodically evaluates the quality of the entities work against Preestablished written criteria

A

Accreditation

53
Q

Data are useful (quality characteristic)

A

Data relevancy

54
Q

Attributes and values of data defined at correct level of detail for intended use

A

Data granularity

55
Q

Term used describe expected data values

A

Data precision

56
Q

A medical condition that coexist with the primary cause for hospitalization and affects the treatment length of stay

A

Comorbidity

57
Q

A medical condition that arises during an inpatient hospitalization

A

Complication

58
Q

Present on admission, a condition present at the time of in patient admission

A

POA

59
Q

The disease or condition that was present on admission, was a principal reason for admission, and receive treatment or evaluation during the hospital stay or visit

A

Principal diagnosis

60
Q

The average weight of all cases treated at a given facility or by a given position which reflects the resource intensity or clinical severity of a specific group in relation to the groups in the classification system

A

Case mix index

61
Q

Organizes the patient info according to the patient care department that provided the care, grouped together according to their point of origin

A

Source orientated health record

62
Q

Documentation approach where the physician defines each clinical problem individually and then organizes it into a database problem list. each problem is indexed with a unique number

A

Problem orientated records

63
Q

Organizes all paper forms in strict chronological order and mixes the forms created by different departments. Easy to follow up course of patient’s treatment but is difficult to compare a similar types of information due to format

A

Integrated orientated health record

64
Q

Progress notes of physicians, nurses, therapist and other authorized individuals will be found together in chronological sequence

A

Integrated record

65
Q

A standard for assessment data tool developed to measure the outcomes of patients receiving home health services under the Medicare and Medicaid programs

A

OASIS

66
Q

Provide context sensitive templates that ensure that the appropriate data are collected and guide users to adhering to professional practice standards

A

Point of care charting

67
Q

Physicians use this for drugs diagnostic studies

A

Computerized provider OE

68
Q

Uniform hospital discharge date is set. List defines a set of common uniform data elements, used in hospitals

A

UHDDS

69
Q

Uniform ambulatory care data set, includes medical and surgical care provided to patient to depart from the facility on the same day they receive care. Physicians offices medical clinics same-day surgery centers, outpatient hospital clinic and diagnostic departments

A

UACDS

70
Q

Minimum data set, long-term care Medicaid and Medicare services

A

MDS

71
Q

Data elements for emergency departments

A

DEEDS

72
Q

Health plan employer data and information sets, population-based data

A

HEDIS

73
Q

The joint commission. Conducts accreditation service and more than 17,000 healthcare organizations including ambulatory care facilities long-term care facilities behavioral health facilities healthcare networks, MCO’s and acute care hospitals

A

TJC

74
Q

Use excess funds to improve their services and to find his education programs and community services

A

Not for profit hospital

75
Q

Privately owned excess funds are paid back to the managers, owners and investors and form of bonuses and dividends

A

For-profit hospitals

76
Q

Not for profit on by and universities, churches, religious orders, unions and other not-for-profit entity

A

Voluntary hospitals

77
Q

The number of sick person’s or cases of disease in relationship to a specific population

A

Morbidity

78
Q

Incidence of death in a specific population

A

Mortality

79
Q

Healthcare provider made up of a number of associated medical facilities that furnish coordinated healthcare services. purpose is to organize continuum of care, maximize effectiveness and reduce costs

A

Integrated healthcare delivery system

80
Q

Patient’s current complaints and symptoms and list his or her past medical personal and family history

A

Medical history

81
Q

Position Sussman of the patient’s current health status. HEENT

A

Physical exam

82
Q

Electronic data interchange. the discrete data from the prescription go directly to the pharmacies information system

A

EDI

83
Q

S=subjective, patients words o=objective data, factual, lab results A=assessment P=plans, what going to do

A

SOAP notes

Health Care Information (1 decks)

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