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HIT 110 > Unit 1 > Flashcards

Unit 1 Flashcards

1
Q

Guide that serves as a pointer or indicator to locate something

A

Index

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2
Q

Facility database of all patients treated in that facility

A

Master patient index

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3
Q

Database used to track patients across multiple facilities (IDS)

A

Enterprise master patient index

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4
Q

Database used to track patients with specific disease processes or a particular surgical procedure

A

Disease and operation index

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5
Q

Database used to track medical cases associated with specific physician(s)

A

Physician index

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6
Q

Chronological listing of all data in a hospital setting

A

Registry

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7
Q

What is the most important resource in any healthcare facility?

A

The MPI

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8
Q

At a minimum the MPI should be able to:

A

Match the name of the patient coming in for treatment with their MPI record
Minimize duplicate records within a facility
Make it easier to merge MPIs
Create an ease for providers to access health records across an IDS or IDN

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9
Q

What does AHIMA stand for?

A

American Health Information Management Associate

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10
Q

Who are clinical professionals

A

Physicians, registered nurses, and physician assistants

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11
Q

What was the Hill-Burton Act?

A

Grants authorizing states to build new hospitals and modernize old ones

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12
Q

What does HIPAA stand for?

A

Health Insurance Portability and Accountability Act

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13
Q

What is meant by “continuum of care?”

A

The right provider, right facility, right time, right care as well as the range of services provided to the patient from emergency to routine

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14
Q

What came into play with the passage of the Public Law 89-97?

A

Medicare and Medicaid

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15
Q

An inpatient is treated in what kind of facility?

A

Acute care

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16
Q

What was the Social Security Act of 1935?

A

It extended the federal governments hand in providing assistance for public health, started during the Great Depression, and provided matching funds for individual states for maternal and infant care, rehab of crippled children, general public health and aid to children under the age of 16

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17
Q

What association(s) provides members with local access to professional HIM education?

A

The Component State and Local Association

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18
Q

What is an “integrated delivery network?”

A

A group of providers, facilities, and community agencies working together

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19
Q

In the AHIMA organization, what functions as the legislative body?

A

The House of Delegates

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20
Q

The right of an individual to control access to their PHI is the definition for…?

A

Privacy

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21
Q

In data quality, expected data values is the definition for…?

A

Precision

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22
Q

The expectation that PHI will be used for its intended purpose during the course of care is known as…?

A

Confidentiality

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23
Q

Data are true to the source and have not been altered or destroyed is the definition for…?

A

Integrity

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24
Q

Authorized users of the health record must be able to access information easily when and where they need it, regardless of format. What data characteristic does to describe?

A

Accessibility

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25
Q

The data quality management domain that refers to the purpose for which data is collected is known as…?

A

Data application

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26
Q

A data characteristic that describes data that are correct and valid is…?

A

Accuracy

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27
Q

ICD-10 CM was developed by…?

A

WHO

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28
Q

The list of data elements collected in individual health records is called…?

A

Data dictionary

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29
Q

What organization is the largest user of healthcare data?

A

TJC

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30
Q

Describes a single fact or measurement=fact

A

Data Element

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31
Q

Refers to data elements that can be used for specific purpose=meaning

A

Information

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32
Q

Recommended data elements with uniform definitions that are relevant for a particular use

A

Data Set

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33
Q

List of data elements collected in individual health records

A

Data Dictionary

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34
Q

Statement of expected behavior against which structures, processes and outcomes can be measured

A

Standards

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35
Q

Data that is extracted from individual health records and combined to create a specific set of information that can be used for many different things

A

Aggregate data

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36
Q

Data that is extracted from individual health records and the patient is identified within this data

A

Patient-specific/identified data or patient identifiable data

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37
Q

Coordinator for development of voluntary standards for several industries

A

ANSI-American National Standards Institute

38
Q

Not for profit organization that provides standards and guidelines to make data exchange possible for hospitals, physicians and other types of healthcare provider systems

A

HL7 Health Level 7

39
Q

Not for profit organization that guides, develops and implements standards and guidelines that help labs improve the quality of lab testing

A

CLNI Clinical and Lab Standards Institute

40
Q

Developed as a universal language for facilities to be able to store, retrieve, and transit data

A

XML Extensive Markup Language

41
Q

Credentialed healthcare worker who is not a physician, nurse, psychologist or pharmacist

A

Allied Health Professional

42
Q

National trade organization that provides education, conducts research, and represents the hospitals industry interests in national legislative matters is…?

A

AHA American Hospital Association

43
Q

National professional membership organization for physicians

A

AMA American Medical Association

44
Q

Number of days stay as an in-patient in the hospital setting

A

ALOS Average Length of Stay

45
Q

Continuous cycle of planning, measuring, and monitoring performance and making improvements

A

CQI Continuous Quality Improvemnt

46
Q

Determine if the medical care to a specific patient was necessary according to the screening criteria

A

UR Utilization Review

47
Q

What is ARRA?

A

American Recovery and Reinvestment Act

Provided stimulus funding during time of economic crisis.
Initiated the beginning of the HITECH Act (Health Information Technology for Economic and Clinical Health)

48
Q

What are the two types of delivery systems?

A

IDN-Integrated Delivery Network

IDS-Integrated Delivery System

49
Q

Admitted into the acute care setting greater than 24 hours depending on the diagnosis and/or procedure

A

Inpatient

50
Q

The patient that is there for 23 hours or less; usually admitted and discharged the same day

A

Outpatient

51
Q

The patient that is admitted for healthcare monitoring for greater than 1 hour but less than 48 hours

A

Observation

52
Q

Short term care provided to diagnose and treat an illness or injury, average length of stay is 30 days or less.

A

Acute Care

53
Q

Preventative and/or corrective healthcare provided in a physicians office, clinic, or hospital, implies the patients is treated and returns home the same day

A

Ambulatory Care

54
Q

Post hospital care for someone still too ill to return home, can be provided in an assisted living facility or a long term care facility

A

Sub-acute Care

55
Q

Care provided to someone that is no longer able to be cared for in the home environment

A

Long-term Care aka-Skilled Nursing Facility (LTC)

56
Q

Healthcare services that are provided to assist patients in achieving and maintaining their optimal level of function, self care, and independence after some type of disability, usually from a car accident or stroke

A

Rehabilitiatin

57
Q

Care provided to those patients with long term disability that only want to receive palliative (comfort) care, this care is provided in the setting of the clients choice

A

Hospice Care

58
Q

Care provided in the patients home with the goal of promoting, maintaining or restoring health or minimizing the effects of their disability or illness, which may include a terminal illness

A

Home Health Care

59
Q

What kind of setting will you have a patient record?

A

Acute care setting

60
Q

What type of setting will you have a medical record?

A

Outpatient setting

61
Q

What type of setting will you have a resident record?

A

Long term care

62
Q

What type of setting will you have a chart?

A

Acute care/paper record

63
Q

What type of setting will you have a client record?

A

Ambulatory, behavioral health, or home health

64
Q

What are the three types of health records?

A

Paper, electronic, and hybrid

65
Q

What is PHI?

A

Personal health information

66
Q

A paper or computer based tool for collecting and storing information about the healthcare services provided to a patient in a single healthcare facility is…?

A

Health record

67
Q

What is the CCHIIM?

A

Commission on Certification for Health Informatics and Information Management

They set the strategic direction for certifications

68
Q

Non-for-profit association dedicated to health information management is…?

A

AHIMA

69
Q

AHIMA outlined data quality management as falling under four domains. What are those?

A

Data applications, data collection, data warehousing, and data analyssi

70
Q

Virtual network used by AHIMA members is…?

A

Communities of Practice

71
Q

True or False

The lab test “hemoglobin: 14.6 gm/110ml” is considered information.

A

False

72
Q

T or F

All the primary purposes of the health record are associated directly with the provision of patent care

A

False

73
Q

T or F
Submitting health record documentation to a third party payer for the purpose of substantiating a patient bill is considered a secondary purpose of the health record

A

True

74
Q

Data is up to date

A

Currency

75
Q

Data and information documented is defined or pertinent

A

Definition

76
Q

Attributes and values of data be defined at the or correct level of detail for intended data usage

A

Granularity

77
Q

What is SDO?

A

Standard Development Organizations

Ex: ANSI, HL7, CLNI, & XML

78
Q

What is CCR?

A

Continuity of Care Record

79
Q

What is CDA?

A

Exchange model for clinical docs

80
Q

What is IEEE?

A

Open systems communication

81
Q

What is CCD?

A

Continuity of Care Document

82
Q

Where are UHDDS used?

A

Hospitals

83
Q

Where are UACDS used?

A

Ambulatory care

84
Q

What is RAP?

A

Resident Assessment Protocol

85
Q

What is OASIS-C?

A

Medicare beneficiaries who receive care from home healthcare agency

86
Q

What is HEDIS?

A

Health Plan Employer Data and Information set- designed to collect admin, claims, and health record review data

87
Q

What is DEEDS?

A

Data Elements for Emergency Department Systems

88
Q

What is EDI?

A

Electronic Data Interchange

89
Q

What is ORYX?

A

JC introduced to integrate outcomes data and other performance measurement data

90
Q

What is NHIN?

A

National Health Information Network

91
Q

What is DICOM?

A

Digital Imaging and Communication in Medicine

92
Q

What is AOA?

A

Type of accrediting body

Is a member association that represents osteopathic physicians

HIT 110 (1 decks)

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