RHIA Exam Terms and Definitions 243 Questions with Verified Answers,100% CORRECT

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RHIA Exam Terms and Definitions 243 Questions with Verified Answers Joint Commission - CORRECT ANSWER This is a private, non-for-profit organization that evaluates and accredits hospitals and other... healthcare organizations on the basis of predefined performance standards. Health record review - CORRECT ANSWER This is a concurrent or ongoing review of health record content performed by caregivers or HIM professionals while the patient is still receiving inpatient services to ensure the quality of the services being provided and the completeness of the documentation being maintained, this is also known as health record analysis: Obliterate errors - CORRECT ANSWER This is the act of altering the original entry by blacking out with marker, using white out, writing over an entry, etc: Abstracting - CORRECT ANSWER This is the process of extracting information from a document or create a brief summary of a patient's illness, treatment and outcome. This is also the process of extracting elements of data from a source document or database and entering them into an automated system: Derived data - CORRECT ANSWER This data consist of factual details aggregated or summarized from a group of health records that provide no means to identify specific patients: Accession number: - CORRECT ANSWER This is a number assigned to each case as it is entered in a cancer registry or for an imaging test: Access control - CORRECT ANSWER This is a computer software program designed to prevent unauthorized use of an information resource/system. This is also a process for designing, implementing, and monitoring a system for guaranteeing that only individuals who have legitimate need are allowed to view or amend specific data: Accession registry - CORRECT ANSWER This is a list of cases in a cancer registry in order in which they were entered: Accounts payable (A/P) - CORRECT ANSWER These are records of payments owed by an organization to other entities: Accounts receivable (A/R) - CORRECT ANSWER These are records of the payments owed to the organization by outside entities such as third-party payers and patients: Accreditation - CORRECT ANSWER This is a voluntary process of institutional or organizational review in which a quasi-independent body created for this purpose periodically evaluates the quality of the entity's work against pre-established written criteria: Acute care prospective payment system (PPS) - CORRECT ANSWER This is a reimbursement system for inpatient hospital services provided to Medicare and Medicate beneficiaries that is based on the use of diagnosis-related groups as a classified tool: Administrative information - CORRECT ANSWER This is information used for administrative and healthcare operations purposes such as billing and quality oversight: Administrative information systems - CORRECT ANSWER This is a category of healthcare information systems that supports human resources management, financial management, executive decision support, and other business-related functions: Advance Beneficiary Notice (ABN) - CORRECT ANSWER This is a statement signed by the patient when s/he is notified by the provider, prior to a service or procedure being done, that Medicare may not reimburse the provider for the service, wherein the patient indicates that s/he will be responsible for any charges: Advance directive - CORRECT ANSWER This is a legal, written document that describes the patient's preferences regarding future healthcare or stipulates the person authorized to make medical decisions in the event the patient is incapable of communicating his or her preferences: Aggregate data - CORRECT ANSWER This is data extracted from individual health records and combined to form de-identified information about groups of patients that can be compared and analyzed: Ambulatory patient classification (APC system) - CORRECT ANSWER Within a group, the diagnoses and procedures are similar in terms of resources used, complexity of illness, and conditions represented. A single payment is made for the outpatient services provided and are based on HCPCS/CPT codes: Global payment - CORRECT ANSWER This is a form of reimbursement used for radiological and other procedures that combines the professional and technical components of the procedures and disperses payments as lap sums to be distributed between the physician and the healthcare facility: Global surgery payment - CORRECT ANSWER This is whey a payment is made for surgical procedures that includes the provision of all healthcare services, form the treatment decision through postoperative patient care: Medicare severity diagnosis-related groups (MS-DRGs) - CORRECT ANSWER This is a system of classifying a Medicare patient's hospital stay into various groups in order to facilitate payment of services: Major diagnosis categories (MDCs) - CORRECT ANSWER To determine the appropriate MS-DRG, a claim for a healthcare encounter is first classified into one of these 25 categories and most are based on body systems and include disease and disorders relating to a particular system: Complication - CORRECT ANSWER This is a secondary condition that arises during hospitalization: Comorbidity (CC) - CORRECT ANSWER This is a condition that existed at admission: Clinical documentation improvement (CDI) program - CORRECT ANSWER This is a process an organization undertakes that will improve clinical specificity and documentation that will allow coders to assign more concise disease classification codes: Alternative hypothesis - CORRECT ANSWER This hypothesis states that there is an association between the independent or dependent variables: Ancillary systems - CORRECT ANSWER These are electronic systems that generate clinical information (such as laboratory information systems, radiology information systems, pharmacy information systems, etc: Application service provider (ASP) - CORRECT ANSWER A third party service company that delivers, manages, and remotely hosts standardized applications software via a network through an outsourcing contract based on fixed, monthly usage or transaction-based pricing: Audit controls - CORRECT ANSWER These are mechanisms that record and examine activity in information systems: Audit log - CORRECT ANSWER This is a chronological record of electronic system(s) activities that enables the reconstruction, review, and examination of the sequence of events surrounding or leading to each event and/or transaction from its beginning to end: Audit trail - CORRECT ANSWER This is a chronological set of computerized records that provides evidence of information system activity (log-ins and log-outs, file accesses) used to determine security violations: Auditing - CORRECT ANSWER This is the performance of internal and/or external reviews to identify variations from established baselines: Authentication - CORRECT ANSWER This is the process of identifying the source of health record entries by attaching a handwritten signature, the author's initials, or an electronic signature. This is the proof of authorship that ensures that log-ins and messages from a user originate from an authorized source: Authorization - CORRECT ANSWER This is the granting of permission to disclose confidential information as defined by HIPAA privacy rule, an individual's formal, written permission to use of disclose his or her personally identifiable health information for purposes other than treatment, payment or healthcare operations: Autoauthentication - CORRECT ANSWER This is a procedure that allows dictated reports to be considered automatically signed unless the health information management department is notified of needed revisions within a certain time limit: Balance billing - CORRECT ANSWER This is a reimbursement method that allows providers to bill patients for charges in excess of the amount paid b the patient's health plan or other third-party payer (not allowed under Medicare or Medicaid): Balance sheet - CORRECT ANSWER This is a report that shows the total dollar amounts in accounts, expressed in accounting equation format at a specific point in time: Balanced scorecard methodology - CORRECT ANSWER This is a strategic planning tool that identifies performance measures related to strategic goals: Bar chart - CORRECT ANSWER This is a graphic technique used to display frequency distributions of nominal or original data that fall into categories: Bar-coding technology - CORRECT ANSWER This is a method of encoding data that consists of parallel arrangements of dark elements, referred to as bars, and light elements, referred to as spaces, and interpreting the data for automatic identification and data collection purposes: Benchmarking - CORRECT ANSWER This is an analysis based on comparison: Best of breed - CORRECT ANSWER This is a vendor strategy used when purchasing an EHR that refers to system application that are considered the best in their class: Best of fit - CORRECT ANSWER This is a vendor strategy used when purchasing an EHR in which all the systems required by healthcare facility area available from one vendor: Bill hold period - CORRECT ANSWER This is the span of time during which a bill is suspended in the billing system awaiting late charges, diagnosis and procedure codes, insurance verification, or other required information: Boxplot - CORRECT ANSWER This is a tool in the form of a graph that displays five-number data summary: Bundled payments - CORRECT ANSWER This is a period of relatively continuous medical care performed by healthcare professionals in relation to a particular clinical problem or situation: Case mix - CORRECT ANSWER This is a description of a patient population based on any number of specific characteristics, including age, gender, type of insurance, diagnosis, risk factors, treatment received and resources used: Case-mix groups - CORRECT ANSWER This is the average relative weight of all cases treated at a given facility or by a given physician, which reflects the resource intensity or clinical severity of a specific group in relation to the other groups in the classification system (calculated by dividing the sum of the weights of diagnosis-related groups for patient discharged during a given period divided by the total number of patient discharged): Certification - CORRECT ANSWER This is the process by which a duly authorized body evaluates and recognizes an individual, institution, or educational program as meeting pre-determined requirements: Champion - CORRECT ANSWER This is someone in the organization who believes in the idea, acknowledges the practical problems and assists in overcoming barriers: Charge capture - CORRECT ANSWER This is the process of collecting all services, procedures and supplies provided during patient care: Chargemaster - CORRECT ANSWER This is a financial management form that contains information about the organization's charges for the healthcare services if provides to patients: Check Sheet - CORRECT ANSWER This is a tool that permits the systematic recording of observations of a particular phenomenon so that trends or patterns can be identified: Claim - CORRECT ANSWER This is an itemized statement of healthcare services and their costs provided by a hospital, physician office, or other healthcare provider; submitted for reimbursement to the healthcare insurance plan either by the insured party or the provider: Claims processing - CORRECT ANSWER This is the process of accumulating claims for services, submitting claims for reimbursement, and ensuring that claims are satisfied: Claims scrubber software - CORRECT ANSWER This is a type of computer program at a healthcare facility that checks for the claim elements of accuracy and agreement before the claims are submitted: Client/Server architecture - CORRECT ANSWER This is a computer architecture in which multiple computers (clients) are connected to other computers (servers) that store and distribute large amounts of shared data: Care plans - CORRECT ANSWER These are care guidelines created by healthcare providers for individual patients for a specified period of time: Clinical practice guidelines - CORRECT ANSWER This is a detailed, step-by-step guide used by healthcare practitioners to make knowledge-based decisions related to patient care and issued by an authoritative organization such as a medical society or government agency: Clinical decision support (CDS) system - CORRECT ANSWER This is a special subcategory of clinical information systems that is designed to help healthcare providers make knowledge-based clinical decisions: Clinical/physician web portals - CORRECT ANSWER This is a media for providing clinical/physician access to the provider organization's multiple sources of data from any network-connected device: Cluster sampling - CORRECT ANSWER This is a process of selecting subjects for a sample from each cluster within a population: Coded data - CORRECT ANSWER This is data that are translated into a standard nomenclature of classification so that they may be aggregated, analyzed and compared: Coding - CORRECT ANSWER This is the process of assigning numeric representations to clinical documentation: Comorbidity - CORRECT ANSWER This is a medical condition that coexists with the primary cause for hospitalization and affects the patient's treatment and length of stay: Conditions of Participation - CORRECT ANSWER This is the administrative and operational guidelines and regulations under which facilities are allowed to take part in the Medicare and Medicaid programs: Data dictionary - CORRECT ANSWER This a descriptive list of the data elements to be collected in an information system or database whose purpose is to ensure consistency of terminology: Data element - CORRECT ANSWER This is an individual fact or measurement that is the smallest unique subset of a database: Data Elements for Emergency Department Systems (DEEDS) - CORRECT ANSWER This is a data set designed to support the uniform of information in hospital-based emergency departments: Data mining - CORRECT ANSWER This is the process of extracting information from a database and then quantifying and filtering discrete, structured data: Data set - CORRECT ANSWER This is a list of recommended data elements with uniform definitions that are relevant for a particular use: Data warehouse - CORRECT ANSWER This is a database that makes it possible to access data from multiple databases and combine the results into a single query and reporting interface: Database - CORRECT ANSWER This is an organized collection of data, text, references, or pictures in a standardized format, typically stored in a computer system for multiple systems: Deemed status - CORRECT ANSWER This is an official designation indicating that a healthcare facility is in compliance with Medicare Conditions of Participation; to qualify for deemed status, facilities must be accredited by the Joint Commission or the American Osteopathic Association: Denial - CORRECT ANSWER This is when a bill has been returned unpaid for any of several reasons: Descriptive statistics - CORRECT ANSWER This is a set of statistical techniques used to describe data such as means, frequency distributions, and standard deviations; statistical information that describes the characteristics of a specific group or a population: Diagnosis-related group (DRG) - CORRECT ANSWER This is unit of case-mix classification adopted by the federal government and some other payers as a prospective payment mechanism for hospital inpatients in which diseases are placed into groups because related diseases and treatments tend to consume similar amounts of healthcare resources and incur similar amounts of cost: Disease index - CORRECT ANSWER This is a list of diseases and conditions of patients sequenced according to the code numbers of the classification system in use: DRG grouper - CORRECT ANSWER This is a computer program that assigns inpatient cases to diagnosis-related groups and determines the medicare reimbursement: Encoder - CORRECT ANSWER This is speciality software used to facilitate the assignment of diagnostic and procedural codes according to the rules of the coding system: Episode-of-care (EOC) reimbursement - CORRECT ANSWER This is a category of payments made as lump sums to providers for all healthcare services delivered to a patient for a specific illness and/or over a specified time period; also called bundled payments because they include multiple services and may include multiple providers: Fee schedule - CORRECT ANSWER This is a list of healthcare services and procedures (usually CPT/HCPCS) codes) and the charges associated with them developed by a third-party payer to represent the approved payment levels for a given insurance plan: Fishbone diagram - CORRECT ANSWER This is a performance improvement tool used to identify or classify the root causes of a problem or condition and to display the root causes graphically: Foreign key - CORRECT ANSWER This is a key attribute used to link one entity or table to another: Free-text data - CORRECT ANSWER This is data that are narrative in nature: Professional component - CORRECT ANSWER This is a portion of a healthcare procedure performed by a physician. Its generally used in reference to the elements of radiological procedures performed by a physician: Group health insurance - CORRECT ANSWER This is a prepaid medical plan that covers the healthcare expenses of an organization's full-time employees: Grouper - CORRECT ANSWER This is a computer software program that automatically assigns prospective payment groups on the basis of clinical codes: Hard-coding - CORRECT ANSWER This is the process of attaching a CPT/HCPCS code to a procedure located on the facility's charge maser so that the code will automatically be included on the patient's bill: Healthcare data analytics - CORRECT ANSWER This is the practice of using data to make business decisions in healthcare: Histogram - CORRECT ANSWER This is a graphic technique used to display the frequency distribution of continuous data (interval or ratio data) as either numbers or percentages in a series of bars: Home health prospective payment system (HH PPS) - CORRECT ANSWER This is the reimbursement system developed by CMS to cover home health services provided to Medicare beneficiaries: Hypothesis - CORRECT ANSWER This is the statement that describes a research question in measurable terms: Hypothesis test - CORRECT ANSWER This allows the analyst to determine the likelihood that a hypothesis is true given the data present in the sample with a predetermined acceptable level of making an error: Identity management - CORRECT ANSWER In the master patient index, these are policies and procedures that manage patient identity, such as prohibiting the same record number for duplicate patients or duplicate records for one patient: Income statement - CORRECT ANSWER This is a statement that summarizes an organization's revenue and expense accounts using totals accumulated during the fiscal year: Informed consent - CORRECT ANSWER This is a type of consent in which the patient should have a basic understanding of which medical procedures or test may be performed as well as risks, benefits and alternatives for those tests or procedures: Integrated health record - CORRECT ANSWER This is a system of health record organization in which all of the paper forms are arranged in strict chronological order and mixed with forms created by different departments: Key attributes - CORRECT ANSWER These are common fields within a relationship database that are used to link tables to one another: Legal health record - CORRECT ANSWER This is a subset of all patient-specific data created or accumulated by a healthcare provider that may be related to third parties in response to legally permissible requests: Licensure - CORRECT ANSWER This is legal authority or formal permission from authorities to carry on certain activities that by law or regulation require such permission: Line graph - CORRECT ANSWER This is a graphic technique used to illustrate the relationship between continuous measurements: Linkage analysis - CORRECT ANSWER This is a technique used to explore and examine relationship among a large number of variables of different types: Longitudinal health record - CORRECT ANSWER This is a permanent, coordinated patient record of significant information listed in chronological order and maintained across time, ideally from birth to death: Many-to-may relationship (M:M) - CORRECT ANSWER This is the concept that multiple instances of any entity may be associated with multiple instances of another entity: Mean - CORRECT ANSWER This is the measure of calculating the average of observations in a frequency distribution: Median - CORRECT ANSWER This is the central tendency that shows the midpoint of a frequency distribution when observations been arranged in order from lowest to highest: Medical necessity - CORRECT ANSWER This is a concept that procedures are only eligible for reimbursement as a covered benefit when they are performed for a specific diagnosis or specified frequency: Minimum data set - CORRECT ANSWER This is the minimum core of defined and categorized patient assessment data that serves as the basis for documentation and reimbursement in an SNF (skilled nursing facility): Medicare Summary Notice (MSN) - CORRECT ANSWER This is a summary sent to the patient from Medicare that summarizes all services provided over a period of time with an explanation of benefits provided: Medicare Provider Analysis and Review (MEDPAR) - CORRECT ANSWER This is a database containing information and files submitted by fiscal intermediaries that is used by the Office of the Inspector General to identify suspicious billing and charge practices: Metadata - CORRECT ANSWER This is descriptive data that characterize other data to create a clearer understanding of their meaning and to achieve greater reliability and quality of information. Metadata consist of both indexing terms and attributes. Data about data: for example, creation date, date sent, date received, last access date, last modification date: Mode - CORRECT ANSWER A measure of central tendency that consists of the most frequent observation in a frequency distribution: Minimum Data Set for Long-Term Care - CORRECT ANSWER This is a federally mandated standard assessment form that Medicare- and Medicaid-certified nursing facilities must use to collect demographic and clinical data on nursing home residents; includes screening, clinical, and functional status elements: National Coverage Determination (NCD) - CORRECT ANSWER This sets forth the extent to which Medicare will cover specific services, procedures, or technologies on a national basis. Nominal-level data - CORRECT ANSWER This is data that fall into groups or categories that are mutually exclusive and with no specific order (for example, patient demographics such as third-party payer, race, and sex); Also called categorical data: Nonparticpating provider (nonPAR) - CORRECT ANSWER Physicians who treat Medicare beneficiaries but do not have a legal agreement with the program to accept assignment on all Medicare services and who, therefore, may bill beneficiaries more than the Medicare reasonable charge on a service-by-service basis Notable disease - CORRECT ANSWER This is a disease that must be reported to a government agency so that regular, frequent, and timely information on individual cases can be used to prevent and control future cases of the disease such as HIV: Normalization - CORRECT ANSWER This is a formal process applied to relational database design to determine which variables should be grouped in a table in order to reduce data redundancy: Nonrandom sampling - CORRECT ANSWER This is a type of convenience or purposive sampling in which all members of the target population do not have an equal or independent chance of being selected for a research study: Null hypothesis - CORRECT ANSWER This is a hypothesis that states there is no association between the independent and dependent variables in a research study: One-to-one relationship - CORRECT ANSWER This is a relationship that exists when an instance of an entity is associated with only one instance of another entity, and vice versa: One-to-many relationship - CORRECT ANSWER This is a relationship that exists when one instance of an entity is associated with multiple instances of another entity One-sample t-test - CORRECT ANSWER This is a test used to compare a population to a standard value: Online/real-time transaction processing (OLTP) - CORRECT ANSWER This is real-time processing of day-to-day business transactions from a database; See online analytical processing: Online analytical processing (OLAP) - CORRECT ANSWER This is a data access architecture that allows the user to retrieve specific information from a large volume of data: Open-record review - CORRECT ANSWER This is a review of the health records of patients currently in the hospital or under active treatment; part of the Joint Commission survey process: Closed-record review - CORRECT ANSWER This is a review of records after a patient has been discharged from the organization or treatment has been terminated: Optical character recognition (OCR) technology - CORRECT ANSWER This is a method of encoding text from analog paper into bitmapped images and translating the images into a form that is computer readable: Ordinal data - CORRECT ANSWER This is a type of data that represents values or observations that can be ranked or ordered: ORYX initiative - CORRECT ANSWER The Joint Commission's initiative that supports the integration of outcomes data and other performance measurement data into the accreditation process: Outcome measures - CORRECT ANSWER This is a measure that indicates the result of the performance: Outpatient prospective payment system (OPPS) - CORRECT ANSWER This is a Medicare prospective payment system used for hospital-based outpatient services and procedures that is predicated on the assignment of ambulatory payment classifications: Pareto chart - CORRECT ANSWER This is a bar graph that includes bars arranged in order of descending size to show decisions on the prioritization of issues, problems, or solutions: Performance measure - CORRECT ANSWER This is a gauge used to assess the performance of a process or function of any organization Per patient per month (PPPM) - CORRECT ANSWER This is a type of managed care arrangement by which providers are paid a fixed fee in exchange for supplying all of the healthcare services an enrollee needs for a specified period of time Pie chart - CORRECT ANSWER This is a graphic technique in which the proportions of a category are displayed as portions of a circle (like pieces of a pie); used to show the relationship of individual parts to the whole: Primary key - CORRECT ANSWER This is an explanatory notation that uniquely identifies each row in a database table: Principal diagnosis - CORRECT ANSWER This is a disease or condition that was present on admission, was the principal reason for admission, and received treatment or evaluation during the hospital stay or visit or the reason established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care: Principal procedure - CORRECT ANSWER This is performed for definitive treatment rather than for diagnostic or exploratory purpose, or necessary to take care of a complication: Problem-oriented medical or health record - CORRECT ANSWER This is a way organizing information in a health record in which clinical problems are defined and documented individually: Quality improvement organization - CORRECT ANSWER This is an organization that performs medical peer review of Medicare and Medicaid claims, including review of validity of hospital diagnosis and procedure coding information; completeness, adequacy, and quality of care; and appropriateness of prospective payments for outlier cases and nonemergent use of the emergency room: Range - CORRECT ANSWER This is a measure of variability between the smallest and largest observations in a frequency distribution: Resident Assessment Instrument (RAI) - CORRECT ANSWER This is a uniform assessment instrument developed by CMS to standardize the collection of skilled nursing facility patient data; this includes the minimum data set: Recovery audit contractor (RAC) - CORRECT ANSWER This is a governmental program whose goal is to identify improper payments made on claims of healthcare services provided to Medicare beneficiaries. Improper payments may be overpayments or underpayments: Resident assessment protocols (RAPs) - CORRECT ANSWER This is a summary of a long-term care resident's medical condition and care requirements, used in conjunction with the MDS to create a clear picture of the patient's status and care plan: Resource-based relative value scale (RBRVS) - CORRECT ANSWER This is a scale of national uniform relative values for all physicians' services. The relative value of each service must be the sum of relative value units representing the physicians' work, practice expenses net of malpractice insurance expenses, and the cost of professional liability insurance: Scatter plot - CORRECT ANSWER This is a graph that visually displays the linear relationships among factors: Simple random sampling - CORRECT ANSWER This is a process of selecting units from a population so that each one has exactly the same chance of being included in the sample: Source-oriented health record - CORRECT ANSWER This is a system of health record organization in which information is arranged according to the patient care department that provided the care: Standard deviation - CORRECT ANSWER This is a measure of variability that describes the deviation from the mean of a frequency distribution in the original units of measurement: Stratified random sampling - CORRECT ANSWER This is a process of selecting the same percentages of subjects for a study sample as they exist in the subgroups (strata) of the population: Strategic IS planning - CORRECT ANSWER There is a process for setting IS priorities within an organization; the process of identifying and prioritizing IS needs based on the organization's strategic goals with the intent of ensuring that all IS technology initiatives are integrated and aligned with the organization's overall strategic plan: Systematic sampling - CORRECT ANSWER This is a process of selecting a sample of subjects for a study by drawing every nth unit on a list Systems development life cycle (SDLC) - CORRECT ANSWER This is a model used to represent the ongoing process of developing (or purchasing) information systems: Technical component (TC) - CORRECT ANSWER The portion of radiological and other procedures that is facility based or nonphysician based (for example, radiology films, equipment, overhead, endoscopic suites, and so on): Terminal-digit filing system - CORRECT ANSWER This is a system of health record identification and filing in which the last digit or group of digits (terminal digits) in the health record number determines file placement: Tracer methodology - CORRECT ANSWER This is a process the Joint Commission surveyors use during the on-site survey to analyze an organization's systems, with particular attention to identified priority focus areas, by following individual patients through the organization's healthcare process in the sequence experienced by the patients; an evaluation that follows (traces) the hospital experiences of specific patients to assess the quality of patient care: Traditional fee-for-service (FFS) reimbursement - CORRECT ANSWER This is a reimbursement method involving third-party payers who compensate providers after the healthcare services have been delivered; payment is based on specific services provided to subscribers: Uniform Bill-04 (UB-04) form - CORRECT ANSWER This is a single standardized Medicare form for standardized uniform billing, implemented in 2007 for hospital inpatients and outpatients; this form will also be used by the major third-party payers and most hospitals: Unbundling - CORRECT ANSWER This is a practice of using multiple codes to bill for the various individual steps in a single procedure rather than using a single code that includes all of the steps of the comprehensive procedure: Uniform Ambulatory Care Data Set (UACDS) - CORRECT ANSWER This is a data set developed by the National Committee on Vital and Health Statistics consisting of a minimum set of patient- or client-specific data elements to be collected in ambulatory care settings: Uniform Hospital Discharge Data Set (UHDDS) - CORRECT ANSWER This is a core set of data elements adopted by the US Department of Health, Education, and Welfare in 1974 that are collected by hospitals on all discharges and all discharge abstract systems: Universal chart order - CORRECT ANSWER This is a system in which the health record is maintained in the same format while the patient is in the facility and after discharge: Upcoding - CORRECT ANSWER This is a practice of assigning diagnostic or procedural codes that represent higher payment rates than the codes that actually reflect the services provided to patients: Use case - CORRECT ANSWER This is a technique that develops scenarios based on how users will use information to assist in developing information systems that support the information requirements: Utilization management (UM) - CORRECT ANSWER This is a collection of systems and processes to ensure that facilities and resources, both human and nonhuman, are used maximally and are consistent with patient care needs and is a program that evaluates the healthcare facility's efficiency in providing necessary care to patients in the most effective manner: Utilization review (UR) - CORRECT ANSWER This is a process of determining whether the medical care provided to a specific patient is necessary according to preestablished objective screening criteria at time frames specified in the organization's utilization management plan: Vocabulary standard - CORRECT ANSWER This is a list or collection of clinical words or phrases with their meanings; also, the set of words used by an individual or group within a particular subject field: Critical path - CORRECT ANSWER This is the path with the great total duration in time and represents the longest duration in time to complete a total project: Project Assumptions - CORRECT ANSWER These are scope-limiting parameters. They provide constraints on what is and is not included in the project: Sponsor - CORRECT ANSWER This is a person who supports, protects and promotes an idea within the organization: Implied consent - CORRECT ANSWER This consent which is not expressly granted by a person, but rather implicitly granted by a person's actions and the facts and circumstances of a particular situation (or in some cases, by a person's silence or inaction): Express consent - CORRECT ANSWER This consent is communicated through words, regardless of whether those words are written or spoken: Interval history - CORRECT ANSWER If the history and physical have been completed within the 30 days prior to admission, there must be an updated entry in the medical record that documents an examination of any changes in the patient's condition since the original history and physical examination and this entry must be included in the record within the first 24 hours of admission, this is called obtaining an: Face sheet - CORRECT ANSWER This is usually the first page of the health record, which contains patient identification, demographics, date of admission, insurance coverage or payment source, referral information, hospital stay dates, physician information, and discharge information, as well as the name of the responsible party, emergency and additional contacts, and the resident's diagnoses: Format - CORRECT ANSWER This refers to the organization of information in the health record: Source-oriented health record - CORRECT ANSWER This is the conventional or traditional method of maintaining paper-based health records. In this method, health records are organized according to the source, or originating, department that rendered the service (for example lab reports are filed together, all radiological reports are filed together): Problem-oriented health record (POMR) - CORRECT ANSWER This is comprised of the problem list, history and physical examination, lab findings, the initial plan and progress notes organized so that every member of the healthcare team can easily follow the course of the patient treatment: SOAP format - CORRECT ANSWER This is the most recognizable component of the problem-oriented health record and it helps providers remember the specific and systematic decision-making process being documented: Integrated health records - CORRECT ANSWER This is arranged in strict chronological order. The order of the record is determined by date the information was entered, the date of service, or the date the report was received, rather by then source department: the record gives the sequence of the patient's care delivered: Quantitative analysis - CORRECT ANSWER This is a review of the health record to determine its completeness and accuracy. This is generally done retrospectively, but may be done while the patient is in the facility, in which it is referred to concurrent review or concurrent analysis: Universal chart order - CORRECT ANSWER When facilities leave the health record in the same format as it was maintained while the patient was in the facility rather than spend the time rearranging the forms this is called: Qualitative analysis - CORRECT ANSWER This is a review of the health record to ensure that standards are met and to determine the adequacy of entries documenting the quality of care. When done when the patient is in the facility it is called open-record review or ongoing review: Serial-unit numbering system - CORRECT ANSWER This is when each patient receives a new number at each visit, and numbers are assigned in straight numerical sequence to consecutive patients in the order in which they arrive for treatment: Unit-numbering system - CORRECT ANSWER This is when each patient is assigned a number during the first encounter for care and keeps it for all subsequent encounters: Terminal-digit filing system - CORRECT ANSWER This is when records are filed according to a three-part number made of up of two digits. Ex 01-02-03, the first part of digits on the right (03) is called the primary number of the terminal-digit, the second pair of digits (02) is called the secondary number and the third pair of digits (01) is called the tertiary or final number: Master patient index (MPI) or enterprise master patient index (EMPI) - CORRECT ANSWER This is a permanent database including every patient ever admitted to or treated by the facility: Overlap - CORRECT ANSWER This occurs when a patient has more than one medical record number assigned across more than one database: Overlay - CORRECT ANSWER This occurs when one patient record is overwritten with dat from another patient's record: Outcomes and Assessment Information Set (OASIS) - CORRECT ANSWER This is a standard core assessment data tool developed to measure the outcomes of adult patients receiving home health services under the Medicare and Medicaid programs: Healthcare Effectiveness Data and Information Set (HEDIS) - CORRECT ANSWER This is a set of standardized performance measures designed to provide healthcare purchasers and consumers with information they need to compare the performance of managed healthcare plans: Divison - CORRECT ANSWER Under ICD-10-PCS, this is a root procedure that involves cutting into a body part without draining fluids or gases from the body part in order to separate or transect the body part, ex: osteotomy: Alteration - CORRECT ANSWER Under ICD-10-PCS, this a root operation that involves modifying the natural anatomic structure of a body part without affecting the function of the body part, ex: facelift: Bypass - CORRECT ANSWER Under ICD-10-PCS, this a root operation that involves altering the route of passage of the contents of a tubular body part, ex: coronary artery bypass: Change - CORRECT ANSWER Under ICD-10-PCS, this a root procedure that involves taking out or off a device from a body part and putting back an identical or similar devices in or on the same body part without cutting or puncturing the skin or a mucous membrane: Control - CORRECT ANSWER Under ICD-10-PCS, a root operation that involves stopping, or attempting to stop, postprocedural bleeding: Creation - CORRECT ANSWER Under ICD-10-PCS, this a root operation that involves making a new genital structure that does not physically take the place of a body part, ex gender change Destruction - CORRECT ANSWER Under ICD-10-PCS, this a root operation that involves physical eradication of all or a portion of a body part by the direct use of energy, force, or a destructive agent, ex: skin lesion: Detachment - CORRECT ANSWER Under ICD-10-PCS, this is a root operation that involves cutting off all or part of the upper or lower extremities: Dilation - CORRECT ANSWER Under ICD-10-PCS, this is a root operation that involves expanding an orifice or the lumen of a tubular body part: Excision - CORRECT ANSWER Under ICD-10-PCS, this is a root operation that involves cutting out or off, without replacement, a portion of a body part: Extirpation - CORRECT ANSWER Under ICD-10-PCS, this is a root operation that involves taking or cutting out solid matter from a body part: Extraction - CORRECT ANSWER Under ICD-10-PCS, this is a root operation that involves pulling or stripping out or off all or a portion of a body part by the use of force: Fragmentation - CORRECT ANSWER Under ICD-10-PCS, this is a root operation that involves breaking solid matter in a body part into pieces: Fusion - CORRECT ANSWER Under ICD-10-PCS, this is a root procedure that involves joining together portions of an articular body part rendering the articular body part immobile: Central model - CORRECT ANSWER This stores patient records in a single database built to allow queries into the system. This model tends to return results quicker than the other models: Decentralized or Federated model - CORRECT ANSWER This maintains the database at each participant's facility. This allows for easy updates to the record: Hybrid model - CORRECT ANSWER This is a cross between the centralized and federal models. This usually entails shared patient consent databases and perhaps the development of shared directories for providers and healthcare facilities for use by all participating organizations: Regional health information organizations (RHIOs) - CORRECT ANSWER These are collaboratives of healthcare providers, payers and patients that regionally exchange healthcare information: Business process reengineering (BRP) - CORRECT ANSWER This is the redesign of the organization and its business processes in order to reduce costs, streamline operations, and improve quality of service: Payback period - CORRECT ANSWER This is the time required to recoup the cost of an investment: Net income - CORRECT ANSWER This is the arithmetic difference between total revenue and total expenses: Accounting rate of return - CORRECT ANSWER This method compares the projected annual cash inflows, minus any applicable annual depreciation, divided by the initial investment: Budget cycle - CORRECT ANSWER This is a complete process of financial planning, operations, and control for a fiscal year; overlaps multiple fiscal years; Also called budget calendar: Depreciation - CORRECT ANSWER This is the allocation of the dollar cost of a capital asset over its expected life: Process measure - CORRECT ANSWER There are measures that focus on a process that leads to a certain outcome, meaning that a scientific basis exists for believing that the process, when executed well, will increase the probability of achieving a desired outcome: Flow chart - CORRECT ANSWER This is a graphic tool that uses standard symbols to visually display detailed information, including time and distance, of the sequential flow of work of an individual or a product as it progresses through a process: Force-field analysis - CORRECT ANSWER This is a performance improvement tool used to identify specific drivers of, and barriers to, an organizational change so that positive factors can be reinforced and negative factors reduced: Predefined process icon - CORRECT ANSWER In flowcharting, this symbol represents formal procedures that participants are expected to carry out the same way every time: Manual input icon - CORRECT ANSWER In flowcharting, this symbol represents a point in the process at which the participants must record data in paper-based or computer based formats: Strategic plan - CORRECT ANSWER This is a document in which the leadership of a healthcare organization identifies the organization's overall mission, vision, and goals to help set the long-term direction of the organization as a business entity: Tactical plans - CORRECT ANSWER This is a strategic plan at the level of divisions and departments: Operational plans - CORRECT ANSWER This is a strategic plan at the lower departmental levels and are implemented as daily activities: Liquidity - CORRECT ANSWER This is the degree to which assets can be quickly and efficiently turned into cash, for example, marketable securities are generally liquid, the assumption being that they can be sold for their full value in a matter of days, whereas buildings are not liquid, because they cannot usually be sold quickly Statement of cash flows - CORRECT ANSWER This details the reasons that cash changed from one balance sheet period to another. It shows the analyst whether cash was used to purchase equipment or to pay down debt and whether any unusually large transactions took place: Statement of retained earnings - CORRECT ANSWER This expresses the change in retained earnings from the beginning of the balance sheet period to the end: Cost-benefit feasibility study - CORRECT ANSWER This is a process that uses quantitative techniques to evaluate and measure the benefit of providing products or services compared to the cost of providing them: Strategy map - CORRECT ANSWER This is a visual representation of the cause-and-effect relationships among the components of an organization's strategy: Work sampling - CORRECT ANSWER This is a work measurement technique that uses random sampling measurements to characterize the performance of the whole: Work distribution analysis - CORRECT ANSWER This is an analysis used to determine whether a department's current work assignments and job content are appropriate: Liability - CORRECT ANSWER This is a legal obligation or responsibility that may have financial repercussions if not fulfilled or an amount owed by an individual or organization to another individual or organization: Needs Assessment - CORRECT ANSWER This is a procedure performed to determine what is required, lacking, or desired by an employee, a group, or an organization: Strategic thinker - CORRECT ANSWER This type of successful leader understand that three competencies can and must be developed such as visioning, strategy development and change management: Serial work division - CORRECT ANSWER This is consecutive handling of tasks or products by individuals or perform a specific function in sequence: Parallel work division - CORRECT ANSWER This is the concurrent handling of tasks or when multiple employees do identical types of tasks: Unit work division - CORRECT ANSWER This is the simultaneous assembly in which everyone performs a different specialized has at the same time: Object-oriented database - CORRECT ANSWER This is considered a basic component of itself and contains data and their relationships in a single structure: Sherman Anti-Trust Act - CORRECT ANSWER Deficit Reduction Act - CORRECT ANSWER False Claims Act - CORRECT ANSWER Data integrity - CORRECT ANSWER Data granularity - CORRECT ANSWER [Show More]

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