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intro health info systems > Module one > Flashcards

Module one Flashcards

1
Q

Abstracting

A

Data entry of codes and other pertinent information. (e.g., patient identification data, admission, discharge dates) utilizing computer software.

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2
Q

Accreditation

A

Voluntary process that a health care facility or organization undergoes to demonstrate that it has met standards beyond those required by law.

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3
Q

Accreditation Council for Graduate Medical Education (ACGME)

A

Professional organization responsible for accrediting medical training programs in the United States through a peer review process that’s based on established standards and guidelines.

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4
Q

Active

A

Medical staff member who delivers most hospital medical services and performs significant organizational and administrative medical staff duties.

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5
Q

Agenda

A

Listing of all items of business to be discussed at a committee meeting

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6
Q

American Recovery and Reinvestment Act

A

Legislation that authorized on expenditure of 1.5 billion in grants for construction, renovation and equipment and for the acquisition of health information technology systems. Health information technology for economic and clinical health act (Hitech Act) was included in American recovery and reinvestment of 2009 and amended the public health service act to establish an office of national coordinator for health information technology within HHS to improve health care quality, safety and efficiency.

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7
Q

Associate

A

Medical staff member who advancement to active category is being considered.

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8
Q

Biometrics

A

An identifier that measures a borrower’s unique physical characteristics or behaviors and compares it to a stored digital template to authenticate the identity of the borrower, such as a fingerprints hand or face geometry and retinal scan or handwritten signature.

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9
Q

Board of Directors
Board of Governors
Board of trustees

A

Membership serves without pay and is represented by professional from the business community; has ultimate legal authority and responsibility for the hospitals operation and is responsible for the quality of care administered to patients also called Board of Directors Board of Governors Board of trustees

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10
Q

By Laws

A

Rules that delineate medical staff responsibility

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11
Q

Chief Residents

A

Position held by Physician in the final year residency (e.g. surgery) or in the year after the residency has been completed (e.g. pediatrics) plays a significant administrative or teaching role in guiding new residents

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12
Q

Code Of Federal Regulations (CFR)

A

Codification of the general and permanent rules published in the federal register by the executive departments and agencies of the federal government

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13
Q

Coding

A

Assigning numeric and alphanumeric codes to diagnoses, procedures, services this function is usually performed by credentialed individuals (e.g. certified coding specialists)

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14
Q

Consulting

A

Label used to describe highly qualified practitioner who is available as a consultant when needed.

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15
Q

Continuum of care

A

Complete range of programs and services, with the type of health care indicating the health care services provided.

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16
Q

Contract services

A

Arranging with outside agencies to perform certain functions, such as health information services, housekeeping, medical waste disposal, clinical services. the purpose of contracting out these services to improve quality while containing cost.

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17
Q

Courtesy

A

Medical staff member who admits and occasional patient to the hospital.

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18
Q

Current Procedural terminology (CPT)

A

Published annually by the American medical associations codes are five-digit numbers assigned to ambulatory procedures and services.

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19
Q

Deemed status

A

Hospital that are accredited by approve accreditation organizations (e.g. the joint commission) are determined to have met or exceeded conditions of participation to participate in the Medicare and Medicaid programs.

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20
Q

Deeming Authority

A

When an accrediting organizations standards have met or exceeded CMS’s conditions of participation for Medicare certification.

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21
Q

Deficit reduction Act of 2005

A

Created the Medicaid integrating program (MIP) which is fraud and abuse detection program.

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22
Q

Digital Signature

A

Type of electronic signature that uses public key cryptography, created using public key cryptography to authenticate a document or message.

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23
Q

Disaster Recovery plan

A

Ensures an appropriate response to internal and external disasters (e.g. explosions) that may effect hospital staff, patients, visitors and community. the plan identifies responsibilities of individuals and departments during the management of a disaster situations.

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24
Q

Do not resuscitate (DNR)

A

An order documented in the patient’s medical records by the physician which instructs medical and nursing staff to not try to revive the patients if breathing or heart stops.

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25
Q

Electronic Health Record EHR

A

Automated record system that contains a collection of information documented by a number of providers at different facilities regarding one patient. has the ability to link patient information created at different locations according to unique patient identifier, provides access to complete and accurate health problems, status treatment data, contains alerts (e.g. Drug interactions) reminders (e.g. prescription renewal notice) for health care providers.

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26
Q

Electronic Signature

A

encompasses all technology options available that can be used to authenticate a document, Generic term that refers to the various methods on electronic documents can be authenticate. including name typed at the end of an email, message by sender, digitalized image of handwritten signature that is inserted or attached to electronic document, secret pin or code (personal identification number) to identify the sender to the recipient unique biometrics-based identifier or digital signature.

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27
Q

Emergency Medical Treatment and Labor Act (EMTALA)

A

Addressed the problem of hospitals failing to screen, treat, appropriately transfer patients, (patients dumping) by establishing criteria for the discharge and transfer of Medicare and Medicaid patients also called the anti-dumping statue.

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28
Q

Federal Register

A

Legal newspaper published every business day by the national archives and records administration (Nara) available paper on microfiche and online.

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29
Q

For Profit

A

Business in which excess income is distributed to shareholders and owners.

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30
Q

Genetic Information Nondiscrimination Act of 2008

A

Prohibits group health plans and health insurance companies from denying coverage to a healthy individual or charging higher premiums based solely on a generic preposition to development of a disease in the future also bars employers from using genetic information when making hiring and firing job replacement and promotion decisions.

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31
Q

Governing Board

A

Membership serves without pay and is represented by professionals from the business community, has ultimate legal authority and responsibility for the hospitals operations and is responsible for the quality of care administered to patients also called board of trustees, governors and directors.

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32
Q

Government Supported Hospitals

A

Not for profit supported by local, regional or federal taxes and operated by local state or federal government also called public hospital.

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33
Q

HCPCS level 2 (national)codes

A

Developed by the centers for Medicare and Medicaid services (CMS) and used to classify report procedures and services, codes are reported to third party payers (e.g. Insurance companies) for reimbursement purposes.

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34
Q

Health Care integrity and protection data bank (HIPDB)

A

Created as a part of HIPAA to combat fraud and abuse in health insurance and health care delivery by alerting users to conduct a comprehensive review of a practitioners, providers, or suppliers past actions.

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35
Q

Health Care Procedure coding system (HCPCS)

A

Comprised of level 1 (CPT) and Level 2 national codes.

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36
Q

Health care proxy

A

Legal document (recognized by the state of New York) in which the patient chooses another person to make treatment decisions in the event the patient becomes in capable of making those decisions.

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37
Q

Health Insurance Portability and accountability Act (HIPAA)

A

Mandated administrative simplifications regulations that govern privacy, security and electronic transactions standards for health care information. Also protects health insurance coverage for workers and their families when they change or lose their job.

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38
Q

Health Plan Employer Data and Information Set (HEDIS)

A

The national committee for quality assurance (NCQA) tool used by health plans to collect data about the quality of care and service they provide.

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39
Q

Hill-Burton Act

A

Provided federal agents to modernized hospitals that had become obsolete due to the lack of capital investment throughout the period of the great depression (1929-1945) in return for federal funds, facilities agreed to provide free or reduced medical services to persons unable to pay.

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40
Q

Hippocrates

A

First physician to consider medicine a science and art separate from the practice of religion.

41
Q

Hippocrates

A

First physician to consider medicine a science and art separate from the practice of religion.

42
Q

Hippocratic Oath

A

Adopted as an expression or early medical ethics and reflected high ideals.

43
Q

Honorary

A

Retired medical staff member who is honored with emeritus status also including outstanding practitioners who the medical staff wish to honor

44
Q

Hospital Administration

A

Serves as a liaison between medical staff and governing board and its responsible for developing a strategic plan for supporting the mission and goals of organization.

45
Q

Hospital Departments

A

Provide direct patient care as well as ancillary (e.g. clinical laboratory) and support services (e.g. Health information department)

46
Q

Hospitalist

A

Physicians who spend most of his or her time in a hospital setting admitting patients to inpatient services from local primary care providers.

47
Q

Human Genome Project

A

Nationally coordinated efforts to characterize all human genetic material by determining the complete sequence of the DNA in the human genome, in 2000 the human genome sequencing was published.

48
Q

Incomplete record Processing

A

Includes the assembly and analysis of discharged patient’s records.

49
Q

Intern

A

Historical term used to designate a physician in the first year of graduate medical education (GME) Since 1975 the accreditation council for medical education (ACGME) has referred to individuals in their first year of GME as residents.

50
Q

International classification of diseases tenth revision clinical modification (ICD-10-CM)

A

Used in the United States to collect information about disease and injuries and to classify diagnoses and procedures.

51
Q

Intranet

A

Private network that utilizes internet protocols and technology and allows users to immediately and simultaneously access health care information with complete security and an audit trail regardless of where users are located.

52
Q

Licensure

A

Obtaining a license to operate.

53
Q

Living will

A

Contains the patient’s instructions about the use of life sustaining treatments.

54
Q

Medicaid (title 19)

A

Joint federal and state programs that helps with medical costs for some people with low incomes and limited resources. Medicaid programs vary from state to state. but most health care cost are covered for those qualify for both Medicare and Medicaid.

55
Q

Medical Staff

A

Licensed physicians and other licensed providers as permitted by law (e.g., nurse practitioners and physician assistant) who are granted clinical privileges.

56
Q

Medical Transcription

A

Accurate and timely transcription of dictated reports (e.g. history, physical examination, discharge summary)

57
Q

Medicare (title 18)

A

Health program for people 65 years of age or older, certain younger people with disabilities, and people with end stage renal disease (ISRD) which is permanent kidney failure treated with dialysis or a transplant.

58
Q

Medicare access and chip reauthorization act of 2015 (MACRA)

A

Legislation that was signed into law on April 16,2015, the act combines the previously established centers for Medicare and Medicaid services programs that included the physician quality reporting system (PQRS) the meaningful use EHR incentive program and the value-based modifier program (VBMP) into a program entitled merit-based incentive payment system (MIPS)

59
Q

Medicare Prescription drug improvement and modernization act of 2003 (MMA)

A

Provides Medicare recipients with prescription drug savings and additional health care plan choices (other than traditional Medicare) Modernizes Medicare by allowing private health plans to compete and requires the Medicare trustees to analyze the combined fiscal status of the Medicare trust funds and warns congress and the president when Medicare general funds subside exceeds 45%

60
Q

Medieval Medicine

A

Developed during the Middle Ages or (dark ages) its most significant event was the construction of hospitals to care for the sick (e.g., bubonic plague).

61
Q

Merit Based Incentive payment system (MIPS)

A

Payment system established as a part the Medicare access and chip reauthorization act of 2015 (MACRA) that was signed into law on April 16,2015 the moves clinician Medicare part b payment to a performance-based payment system

62
Q

Middle Ages

A

Characterized by lack of education except among nobility and the most wealthy also called the dark ages.

63
Q

Minutes

A

Concise, accurate records of actions taken, and decisions made during a meeting.

64
Q

Modern Medicine

A

Characterized by the implementation of standards for sanitation ventilation, hygiene and nutrition, in addition choosing health care as a profession become more acceptable hospitals were reformed and training of physicians and nurses improved.

65
Q

National Practitioner data bank (NPDB)

A

Established by the federal health care quality improvement act of 1986.It contains information about practitioner’s credentials, including pervious medical malpractice payment and adverse history state licensing board hospitals and other health care facilities access the NPDB to identify and discipline practitioners who engage in unprofessional behaviors.

66
Q

Not for Profit

A

Excess income is reinvested in the facility.

67
Q

ORYX initiative

A

Introduced by the joint commission to integrate outcomes and other performance measurement data into the accreditation process.

68
Q

Paleopathology

A

Study of human remains

69
Q

Papyrus

A

Loose textured porous white paper used a writing material and made from a papyrus water plant.

70
Q

Patient safety and Quality improvement act of 2005

A

Amends title IX of the public health service act to provide improved patient safety and reduced incidence of events adversely affecting patient safety.

71
Q

Patient Self Determination Act

A

Requires consumers to be provided with informed consent information about their right to make advance health care decisions (called advance directives) and information about state laws that impact legal choices in making health care decisions.

72
Q

Physician Quality Reporting Initiative (PQRI)

A

The tax relief and health care act of 2006(TRHCA)authorized implementation to establish a financial incentive for eligible professionals who participate in a voluntary quality reporting program

73
Q

Prehistoric medicine and ancient medicine

A

Characterized by the belief that illness was caused by the supernatural an attempt to explain changes in body function that were not understood (e.g. evil spirits were said to have invaded the body of the sick person)

74
Q

primary care

A

Services include preventive and acute care that are referred to as the point of first contact and are provided by a general practitioner or health care professionals (e.g. nurse practitioner) who has first contact with a patient seeking medical treatment including general dental, ophthalmic and pharmaceutical services.

75
Q

Proprietary Hospital

A

For profit hospital owned by corporations (e.g. Humana) partnership (e.g. Physicians) or private foundations (e.g. tarpon springs hospital foundation Inc) which does business as Helen Ellis memorial hospital in tarpon springs Florida.

76
Q

Public Hospital

A

not for profit supported by local, regional or federal taxes and operated by local and state or federal government.

77
Q

Public Key Cyptography

A

Attaches on alphanumeric number to a document that is unique to the document and to the person signing the document uses and algorithm of two keys one for creating the digital signature by transforming data into a seemingly unintelligible form and return the message to its original form.

78
Q

Quality improvement organizations (q-10)

A

New name for peer review organizations (pros)q10 continue to perform quality control and utilization review of health care furnished to Medicare beneficiaries.

79
Q

Quaternary care

A

Considered as an extension of tertiary care, and includes advanced level of medicines that are highly specialized not widely used (e.g., experimental medicine and very costly it is typically provided by tertiary care center).

80
Q

Record Circulation

A

Includes the retrieval of patient records for the purpose of inpatient readmission scheduled and unscheduled outpatient clinic visit authorized quality management studies and education and research.

81
Q

Regulation

A

Interpretation of a law written by a responsible regulatory agency such as centers for Medicare and Medicaid services (CMS)

82
Q

Renaissance Medicine

A

Mostly associated with Europe was characterized by a renewed interest in the arts, sciences and philosophy. this was the beginning of modern medicine based on education instead of spiritual beliefs.

83
Q

resident’s

A

Physician who has completed of internship and is engaged in a program of training designed to increase his or her knowledge of the clinical disciplines of medicine, surgery or any of the other special fields that provide advanced training in preparation for the practice of a specialty.

84
Q

Rules and Regulations

A

Procedures based on federal and state regulations and accreditation standards which clarify medical staff by laws.

85
Q

Secondary Care

A

Services provided by medical specialists or hospital staff member to a patient who primary care was provided by a general practitioner who first diagnosed or treated the patient (the primary care providers refer the patient to the specialist).

86
Q

Shared visions- new pathways

A

Introduced by the joint commission in 2003 to radically change the survey process so it focuses on whether the organization is making improvements system wide facilities will adopt a continuous survey process starting in 2004 which means survey preparation will be an ongoing process (instead of the traditional once every three years labor intensive preparation that proved not to impact on improving patient care)

87
Q

Smart card

A

Plastic card that contains a small central processing unit some memory and a small rectangular gold colored contract area that interacts with a smart card reader.

88
Q

standards

A

Measurements developed by a accreditation organization to evaluate a health care organizations level of performance in specific care (usually more rigorous than regulations).

89
Q

state children health insurance program (SCHIP)

A

Health Insurance program for infants, children and teens that cover health care services such as doctor’s visits, prescription medicines and hospitalizations also called title XXI of the balanced budget act of 1997.

90
Q

State Department of health

A

Departments established by state governments to oversee health concerns within a state.

91
Q

Survey

A

Evaluation process conducted off site and on site to determine whether the facility complies with standards.

92
Q

Tax Equity and Fiscal responsibility act of 1982 (TEFRA)

A

Established that first Medicare prospective payment system called diagnoses related groups (DRGs)which was implemented in 1983.

93
Q

Teaching Hospital

A

Government (not for profit) proprietary (for profit) or voluntary (non-profit) hospitals that are affiliated with a medical school.

94
Q

Tertiary Care

A

Services provided by specialized hospitals equipped with diagnostic and treatment facilities not generally available at hospitals other than primary teaching hospitals or level 1,2,3 or IV trauma centers.

95
Q

Title XXI of the Balanced budget act 1997

A

Health insurance that covers infants, children, and teens for health care services.
see state children health insurance programs.

96
Q

Triage

A

An organized method of identifying and treating patients according to urgency of care required

97
Q

Universal chart order

A

Discharged patient record is organized in the same order as when the patient was on the nursing floor eliminates the time-consuming assembly task performed by the health information department.

98
Q

Veterans

A

Individuals who have served in the United States military and who are eligible to receive care to VA medical centers (VAMC’s) located throughout the United States.

99
Q

Voluntary Hospitals

A

not for profit hospitals operated by religious or other voluntary groups (e.g. Shriners)

intro health info systems (2 decks)

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