Domain 1 Flashcards

Data Content, Structure, and Information Governance

1
Q

MPI

A

Master Person Index

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2
Q

(ac·ces·sion)

A

position of rank or power

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3
Q

Cancer Registry

A

Is the number assigned to each case as it is entered into a cancer registry

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4
Q

ASTM

A

American Society for Testing and Materials

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5
Q

EHR

A

electronic health record

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6
Q

COPE

A

Computerized Provider Order Entry

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7
Q

Systematized Nomenclature of Medicine Clinical Terminology

A

provides a standardized vocabulary for facilitating the development of computer-based patient records

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8
Q

Subjective (S.O.A.P)

A

Subjective (S) entry relates significant information in the patient’s words or from the patient’s point of view

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9
Q

PHR

A

Personal Health Record

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10
Q

American College of Surgeons (ACS) in 1918

A

Establish minimum quality standards for hospitals

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11
Q

RAI

A

Resident Assessment Instrument

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12
Q

Ambulatory care

A

the practice of providing medical services in an outpatient setting.

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13
Q

What type of health records may contain family and caregiver input?

A

Behavioral health records (Mental Health)

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14
Q

Validity

A

Validity is the degree to which codes accurately reflect the patient’s diagnoses and procedures

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15
Q

SNOM–ED– CT

A

Systematized Nomenclature of Medicine Clinical Terminology

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16
Q

Data dictionary

A

improves data validity and reliability within, across, and outside the enterprise

17
Q

Interoperability

A

Interoperability refers to the use of standard protocols to enable two different computer systems to share data with each other