Ch2 Vocab Flashcards

1
Q

Administrative information

A

Information used for administrative and healthcare operations purposes, such as billing and quality oversight.

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2
Q

Allied Health professional

A

A credentialed healthcare worker who is not a physician, nurse, psychologist, or pharmacist. Such as physical therapist, dietitian, social worker, or occupational therapist

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3
Q

Certification Commission for Healthcare Information Technology (CCHIT)

A
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4
Q

Computer-based patient record (CPR)

A
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5
Q

Critical access hospital (CAHs)

A
  1. Hospitals that are excluded from the outpatient prospective payment system because they are paid under a reasonable cost-based system as required under section 1834(g) of the Social Security Act 2. Under HITECH incentives, a facility that has been certified as a critical access hospital under section 1820(e) f the Act and for which Medicare payment is made under section 1814(1) of the Act for inpatient services and under section 1864(g) of the Act for outpatient services
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6
Q

Derived data

A

Factual details aggregated or summarized from a group of health records that provide no means of identifying specific patients

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7
Q

Destruction

A

under ICD-10-PCS, a root operation that involves physical eradication of all or a portion of a body part of the direct use of energy , force, or a destructive agent

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8
Q

Health information management (HIM) professionals

A

an individual who has received professional training at the associate or baccalaureate degree level in the management of health data and information flow throughout healthcare delivery system

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9
Q

Health Level Seven (HL7) International

A

A not-for-profit, ANSI-accredited standards-developing organizations dedicated to providing a comprehensive framework and related standards for the exchange, integration, sharing, and retrieval of electronic health information that supports clinical practice and the management, delivery, and evaluation of health services

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10
Q

Health record

A
  1. Information relating to the physical or mental health or condition of an individual, as made by or on behalf of a health professional in connection with the care ascribed that individual. 2 A medical record, health record, or medical chart that is a systematic documentation of a patient’s medical history and care
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11
Q

Legal health record

A

Documents and data elements that a healthcare provider may include in response to legally permissible requests for patient information.

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12
Q

Longitudinal health record

A

A permanent, coordinated patient record of significant information listed in chronological order and maintained across time, ideally from birth to death

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13
Q

National Committee on Vital and Health Statistics (NCVHS)

A

Established by COngress to serve as an advisory body to HHS on health data, statistics, and national health information policy. It fulfills important review and advisory functions relative to health data and statistical problems of national and international interest, stimulates or conducts studies of such problems and makes proposals for information to the nation’s health statistics and information systems. In 1996 the committee was restructured to meet expanded responsibilities under HIPPA

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14
Q

National Council for Prescription Drug Programs (NCPDP)

A

a not-for-profit ANSI-accredited standards development organization founded in 1977 that develops standards for exchanging prescription and payments information

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15
Q

Nationwide Health Information Network (NHIN)

A
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16
Q

Nationwide Health Information Network Exchange

A

a group of federal agencies and non-federal organizations that came together under a common mission and purpose to improve patient care, streamline disability benefit claims, and improve public health reporting through secure, trusted, and interoperable health information exchange.

17
Q

Protected health insurance

A
18
Q

Release and disclosure

A

the process that make health record information available to legitimate users

19
Q

Release of information (ROI)

A

the process of disclosing patient-identifiable information from the health record to another party

20
Q

Retention

A

1 Mechanisms for storing records, providing for timely retrieval, and establishing the length of times that various types of records will be retained by the healthcare organization 2 The ability to keep valuable employees from seeking employment elsewhere.

21
Q

Source-system data

A

1 a system in which data were originally created 2. Independent information system application that contributes data to an EHR, including departmental clinical applications and specialty applications

22
Q

Systematized Nomenclature of Medicine-Clinical Terms (SNOMED CT)

A

The most comprehensive, multilingual clinical healthcare terminology in the world. Contributes to the improvement of patient care by underpinning the development of electronic health records that record clinical information in ways to enable meaning-based retrieval

23
Q

Working document

A

Documents that have not been finalized