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HIM 5010 > Exam 2 > Flashcards

Exam 2 Flashcards

1
Q

ARRA

A

American Recovery and Reinvestment Act of 2009 - Amended the HIPAA rules. The key goal is to create a national standard for the configuration and content of health records so that health information can be easily shared among providers of different organizations. (the goal is complete EHR)

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2
Q

Source-Oriented Health Record

A

Documents are grouped according to their point of origin. Labs with labs, imaging with imaging, progress notes with progress notes, etc.

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3
Q

Problem-Oriented Health Record

A

Is arranged according to a problem list. Each problem is indexed with a unique number, and reports and clinical documentation are keyed to the numbers representing the problems they address. They are arranged in chronological or reverse chronological order.

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4
Q

SOAP

A

Information in progress notes is organized using this sequence.
S - Subjective Information (such as a patient complaint)
O - Objective data (such as diagnostic test results)
A - Assessment (diagnosis)
P - Plan (treatment)

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5
Q

Integrated Health Record

A

Is arranged so that the documentation from various sources is intermingled and follows a strict chronological or reverse chronological order. The advantage is that it’s easy for caregivers to follow the course of the patient’s diagnosis, but difficult to compare related information or to even locate specific information. Used in paper charts.

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6
Q

Structured Data

A

Generally found in checkboxes and drop-down boxes

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7
Q

Unstructured Data

A

Also called narrative data, can be entered in a free next format

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8
Q

ONC

A

Office of the National Coordinator for Health Information Technology - Is within the Department of Health and Human Services (HHS). job is to oversee the development of an NHII (National Health Information Infrastructure)

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9
Q

NHII

A

National Health Information Infrastructure - a framework that will support the appropriate and secure exchange of health information among organizations throughout the nation.

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10
Q

AHRQ

A

Agency for Healthcare Research and Quality - One of the HHS agencies that provides funding and information for health information technology projects, including grants and state and regional health information exchange (HIE)

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11
Q

Meaningful Use Criteria

A

A term used by the federal government to describe the requirements healthcare providers must meet to receive incentive payments for implementing different phases of an EHR between 2011 and 2015. There are 3 stages of meaningful use criteria.

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12
Q

Stage 1 - Meaningful Use Criteria

A

Focuses on electronically capturing health information in an encoded format; using that information for care coordination purposes.

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13
Q

Stage 2 - Meaningful Use Criteria

A

Encourages the use of health information technology for continuous quality improvement at the point of care and the exchange of information in the most structured format possible, such as the electronic transmission of orders entered.

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14
Q

Stage 3 - Meaningful Use Criteria

A

Expands on stage 2. Focuses on promoting improvements in quality, safety, and efficiency; using decision support for national high-priority conditions; ensuring patient access to self-management tools; providing access to comprehensive patient date; and improving population health.

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15
Q

What are the 3 National Health Information Network (NHIN) Standards?

A
  1. Structure and content standards
  2. Functionality standards
  3. Technical standards
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16
Q

Structure and Content Standards

A

On of the standards of the National Health Information Network - establishes and provides clear and uniform definitions of the data elements to be included in EHR systems. They specify the type of data to be collected in each data field, the length of each data field, and the attributes of each data field, all of which are captured in data dictionaries.

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17
Q

Functionality Standards

A

One of the standards of the National Health Information Network - Defines the components an EHR needs to support the functions for which it is designed.

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18
Q

Technical Standards

A

One of the standards of the National Health Information Network - Complement content and structure, and vocabulary standards are also required to make interoperability possible. Technical standards provide the rules for how these data are transmitted from one computer system to another.

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19
Q

CCHIT

A

Certification Commission for Health Information Technology - is a non-profit organization with the public mission of accelerating the adoption of health IT. The commission established the first comprehensive practical definition of what capabilities were needed in these systems.

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20
Q

ANSI

A

American National Standards Institute - A private, non-profit organization founded to coordinate the US census systems. Today, ANSI approves official American national standards and includes membership from all sectors, not just healthcare. They are responsible for accrediting healthcare standards development organizations in the U.S.

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21
Q

Data Dictionary

A

A centralized repository of information about data that includes elements such as meaning, relationships to other data, origin, usage, and format. The purpose is to standardize definitions and ensure consistency of use.

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22
Q

Database

A

An organized collection of data that have been stored electronically for easy access.

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23
Q

DBMS

A

Database Management Systems - An integrated set of programs that helps users store and manipulate data easily and efficiently. DBMSs make it possible to create, modify, delete, and view the data in a database.

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24
Q

Clinical Data Repository

A

A centralized database that captures, sorts, and processes patient data and then returns them to the user.

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25
Q

What are other names for messaging standards?

A

Interoperability Standards and Data Exchange Standards

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26
Q

CDS

A

Clinical Decision Support - A clinical system, application, or process that helps health professionals make clinical decisions to enhance patient care. CDS systems help physicians and other clinicians make diagnostic and treatment decisions.

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27
Q

Electronic Signature

A

A unique personal identifier that is entered by the author of EHR documentation via electronic means.

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28
Q

Digital Signature

A

A digitized version of a handwritten signature. The author sings his or her name on a pen pad, and the signature is automatically converted into a digital signature that is affixed to the electronic document.

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29
Q

Unique Personal Identifier

A

A code or password

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30
Q

Biometric Identifier

A

A fingerprint or retinal scan

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31
Q

Discovery

A

The formal, pretrial legal process used by parties to a lawsuit to obtain information. Discovery helps ensure that neither party is subjected to surprises at trial.

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32
Q

Health Data Repository

A

A database that provides immediate national access to local data in the event of primary system failure or system unavailability. The repository is an effort to improve data accessibility and increase disaster preparedness.

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33
Q

Data

A

Data are the dates, numbers, images, symbols, letters, and words that represent basic facts and observations about people, processes, measurements, and conditions.

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34
Q

Information

A

Is factual data that have been collected, combined, analyzed, interpreted, and/or converted into a form that can be used for a specific purpose.

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35
Q

Financial Data

A

Information about patient’s occupation, employer,and insurance coverage.

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36
Q

Implied Consent

A

Is assumed when a patient voluntarily submits to medical treatment.

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37
Q

Expressed Consent

A

Is permission that is either spoken or written. (consent to treatment) Patients are usually asked to sign a general consent form during the registration and admissions process.

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38
Q

Informed Consent

A

A more specific consent required for procedures that involve significant risk.

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39
Q

Advance Directive

A

A written document that describes the patient’s healthcare preferences in the event that she becomes unable to communicate. Involves items such as living wills and statements of the patient’s wishes in case of critical illness.

40
Q

Who regulates the Health Record Content?

A
  1. The Federal Government - via Centers for Medicare and Medicaid Services identifies the minimum clinical content requirements for patient health records.
  2. The Joint Commission - a not-for profit standards setting organization providing accreditation and evaluation services for most types of healthcare sites.
  3. Medical Staff Bylaws - A collection of guidelines adopted by a hospitals medical staff to govern its business conduct and the rights and responsibilities of its members. Approved by the board of trustees.
41
Q

Who obtains the patient’s history and conducts the physical exam?

A

The attending physician, or his or her designee (who may be a resident, physician assistant, or nurse practitioner). But the attending physician is ultimately responsible for the content and quality of the exam and its documentation.

42
Q

What are Medical Conditions of Participation’s time requirements for performing a physical examination?

A

Medicare requires that the admitting physician perform an initial physical examination within 24 hours of admission. Documentation of medical history, consents, and the physical examination must be available in the patient’s record before any surgical procedures may be performed.

43
Q

Interval Note

A

Can be added to the patient’s record in place of a complete history and physical when patients are readmitted to the same hospital for treatment of the same condition within 30 days of previous discharge. Includes information about the patient’s current complaint, any relevant changes in his or her condition, and the physical findings since the last admission. However, when the patient is admitted for treatment of a different condition, a complete history and physical must be performed.

44
Q

Standing Orders

A

Are routine physicians orders that have been established by individual physicians or by the hospital’s medical staff. Each standing order applies to a specific diagnosis or procedure.

45
Q

DNR

A

Do-Not-Resuscitate Order - are issued when the patient or the patient’s legal representative decides that if the patient is near death, no resuscitation attempts should be made when the patient stops breathing.

46
Q

Discharge Order

A

Only the patient’s attending physician can decide when the patient is ready to be discharged from the hospital. They must be documented. When a patient leaves the hospital against medical advice, a note describing the situation should be included in the patient’s health record. When a patient dies, a similar not should be added to the health record in lieu of a discharge order.

47
Q

What healthcare professionals are allowed to enter clinical documentation into the health record?

A

Typically the patient’s principal physician, consulting physician’s, house medical staff, nurses, dietitians, social workers, and clinical therapists. They must sign and date all of their record entries and include their credentials after their names.

48
Q

When must progress notes be entered?

A

Physicians must document a progress not every time they visit with or provide treatment to the patient, and progress notes should be documented at least daily.

49
Q

Nursing Assessment

A

Is always performed to obtain clinical and personal information about the patient shortly after she has been admitted to the nursing unit.

50
Q

What are the State, Joint Commission, and Federal guideline time requirements for nursing assessments?

A

Hospitals are required to provide a nursing assessment within 24 hours of admission.

51
Q

Care Plan

A

A care plan is a multidisciplinary tool for organizing the diagnostic and therapeutic services to be provided to a patient.

52
Q

What are the current accreditation standards for care plans?

A

Current accreditation standards and the Medical Conditions of Participation require hospitals to develop patient-specific care plans. Care plans are also required in the long-term care setting and other inpatient environments.

53
Q

Clinical Practice Guidelines

A

Detailed step-by-step guides used by healthcare practitioners to make knowledge-based clinical decisions directly related to patient care. They are developed with the goal of standardizing clinical decision making.

54
Q

Clinical Protocols

A

Treatment recommendations that are often based on clinical practice guidelines.

55
Q

Clinical Pathways

A

Structured plans of care that help organizations implement clinical guidelines and protocols. Sometimes known as critical paths, care paths, or care maps, they are widely used by institutions hoping to reduce costs and improve quality through decreased variation in practices.

56
Q

Care Management

A

Involves a process of ongoing and concurrent review performed to ensure the medical necessity and effectiveness of the clinical services being provided to the patient.

57
Q

MAR

A

Medication Administration Record - Includes all of the medications administered to the patient while the patient is in the nursing unit.

58
Q

Flowcharts

A

Are graphic illustrations of data and observations. They make it easy to visualize patterns and identify abnormal results and are often used in addition to narrative progress notes for recording the patient’s fluid consumption and elimination patterns.

59
Q

Ancillary Services

A

Are diagnostics or therapeutic services provided to hospital patients other than those provided by physicians or nurses. They include laboratory, nuclear radiology, and some cardiology and neurologic testing.

60
Q

Preoperative Anesthesia Evaluation

A

Regulations and accreditation standards require anesthesiologists and certified nurse anesthesiologists to perform and document a preoperative anesthesia evaluation for every patient to whom anesthesia is administered.

61
Q

Intraoperative Anesthesia Record

A

The professional administering anesthesia must also maintain an intraoperative anesthesia record and vital signs while the procedure is being performed.

62
Q

Postoperative Anesthesia Record

A

Contain information on any unusual events or complications that occurred during surgery. It also documents the patient’s condition at the conclusion of surgery and after recovery from anesthesia.

63
Q

Operative Report

A

A formal document prepared by the principal surgeon to describe the surgical procedures performed for the patient. It should be written or dictated immediately after surgery and filed in the patients health record as soon as possible.

64
Q

Discharge Summary

A

A concise account of the patient’s illness, course of treatment, response to treatment, and condition at discharge. The summary states the patient’s reason for admission, and gives a brief history explaining why he or she needed to be hospitalized.

65
Q

When must a discharge summary be completed?

A

The attending physician (or designee) is responsible for completing the summary within 30 days of discharge for most patients, but within 24 hours for patients transferred to other facilities. Discharge summaries are not always required for patients who were hospitalized for less than 48 hours.

66
Q

Clinical Documentation

A

Is any manual or electronic notation (or recording) made by a physician or other healthcare clinician related to a patient’s medical condition or treatment.

67
Q

EBM

A

Evidence-Based-Medicine - Means practicing medicine using only the best scientific data available.

68
Q

What are the 7 criteria for high-quality clinical documentation?

A
  1. Legible
  2. Reliable
  3. Precise
  4. Complete
  5. Consistent
  6. Clear
  7. Timely
69
Q

Concurrent Query

A

A question posed to the documenting physician during the patient’s hospital stay to obtain additional, clarifying documentation to improve both the quality of documentation and the treatment of the patient.

70
Q

Retrospective Query

A

A question posed to the documenting or attending physician after the patient has been discharged to obtain additional, clarifying documentation to improve the specificity and completeness of the data used to assign diagnosis and procedure codes in the patient record.

71
Q

How long after discharge is the health record in the hands of a hospital coding professional?

A

Within about 48 hours.

72
Q

Encoder

A

A computer program that assists the coder in assigning ICD-9-CM or CPT codes to the documentation in the patients health record.

73
Q

CMI

A

Case-Mix Index - is the average relative weight for all inpatients in a hospital. CMI reflects the expected intensity of resources needed to care for patients.

74
Q

CC

A

Complication and/or Comorbidity - Are secondary diagnoses that, if documented, are likely to increase the intensity of services needed to care for the patient.

75
Q

DRGs

A

Diagnosis-Related Groups - are a way to group ICD-9-CM coded data from an inpatient stay into categories that are similar clinically and in the intensity of services they are likely to require. Each DRG is assigned a relative weight based on the intensity of services patients in that DRG are likely to require.

76
Q

Medicare Quality Indicators

A

These are criteria determined by Medicare that, if not present in a patient’s record, are likely to result in higher quality of care than if they are not present. Examples include smoking cessation counseling and aspirin given to patients with acute MI within minutes of their admission.

77
Q

Severity of Illness (SOI)

A

A system of classifying inpatient cases into categories that are likely to be similar in severity using demographic and clinical information.

78
Q

Health Record Analysis

A

Is the review of patient records to ensure the quality and completeness of clinical documentation. Is generally performed after the patient is discharged.

79
Q

Quantitative Analysis

A

Is a review of the health record to determine its completeness and accuracy.

80
Q

Qualitative Analysis

A

Is a review of the health record to ensure the quality of clinical documentation.

81
Q

Deficiency Systems

A

May be paper based, computer based, or electronic. Is designed to track and report elements of documentation missing from health records.

82
Q

Medical Record Delinquency Rate

A

The Joint Commission requires hospitals to monitor the medical record delinquency rate quarterly.

83
Q

Regulation

A

A rule established by an administrative agency of government. Regulations have the same effect as legislation - failure to abide by regulations or statuses results in fines and/or disciplinary action.

84
Q

For what reasons can a healthcare facility disclose patient PHI without a patient’s authorization?

A
  • Required by law - statute, regulation, or court order
  • Public Health Activities
  • Victims of abuse, neglect, or domestic violence
  • Health oversight activities - audits and investigations
  • Judicial & Administering proceedings - court order
  • Law enforcement purposes
  • Decedents - may disclose PHI to funeral directors and medical examiners
  • Cadaveric organ, eye, or tissue donation
  • Research
  • Serious threat to health or safety
  • Workers’ compensation.
85
Q

Limited Data Set

A

Is PHI from which certain specified direct identifiers of individuals and their relatives, household members, and employers have been removed. May be used and disclosed for research.

86
Q

What 5 areas does the HITECH Act address?

A
  1. Standards and Certification
  2. Meaningful Use
  3. Privacy and Security
  4. Electronic Eligibility and Enrollment
  5. Electronic Prescriptions
87
Q

Deemed Status

A

Means accrediting bodies such as the Joint commission or AOA, can survey facilities for compliance with the Medicare COP in place of the government.

88
Q

What are the 5 components of a compliance plan?

A
  1. Standards of conduct and policies and procedures
  2. Compliance plan development and validation
  3. Education and training of nonmedical and medical staff
  4. Monitoring of high-risk activities
  5. Auditing of high-risk activities
89
Q

What is the main difference between monitoring and auditing?

A

Monitoring is less formal and is performed regularly (daily, weekly, or monthly) by internal employees, and auditing is more formal and is performed less frequently (annually or quarterly) by an external professional services firm.

90
Q

Licensure

A

Is the mandatory process whereby state governments grant individual facilities permission to operate within a specific geopolitical area and provide a specific range of healthcare services.

91
Q

Accreditation

A

A systematic quality review process that evaluates the healthcare facility’s performance against preestablished, written criteria, or standards.

92
Q

PPR

A

The Joint Commission uses a Periodic Performance Review that is designed to promote continuous standards compliance. The PPR was created to help hospitals shift from a mentality of survey preparation to one of continuous improvement.

93
Q

PFP

A

Priority Focus Process - Focusing survey activities on the organization-specific issues that are most relevant to safety and quality of care.

94
Q

Tracer Methodology

A

The Joint Commission uses this for on-site surveys. Follows the experience of care through the organizations entire healthcare process and allow the surveyor to identify performance issues.

95
Q

Sentinel Event

A

An unexpected occurrence involving death, serious physical or psychological injury, or the risk thereof. (Loss of limb or function)

HIM 5010 (2 decks)

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