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Mid Term Flashcards

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0
Q

HIM was recognized as a allies health profession in

A

1928

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1
Q

AHIMA’s primary fx is

A

To promote accuracy, confidentiality and accessibility of health records.

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2
Q

What is CoP?

A

A virtual network of AHIMA members for communicating via web based program through a AHIMA. Is only open to members and provides contact for quick problem-solving and support

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3
Q

What is CPT?

A

Current procedural terminology in. Are used to report physician services to the Medicare program to determine reimbursement

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4
Q

What is DSM-IV-TR?

A

American psychiatric Association diagnostic and statistical manual of mental disorders. Glossary of mental disorders

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5
Q

What is HCPCS?

A

Healthcare common procedure coding system. Collection of codes and descriptions used to represent healthcare procedures supplies products and services

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6
Q

ICD-9-CM

A

International classification of diseases, 9th revision clinical modification. Value one top your list, numerical code to represent diseases and injuries. Volume two alphabetical list for all codes and volume one. Volume three only use the US

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7
Q

ICD-10-CM

A

International classification of diseases 10th revision clinical modification

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8
Q

ICD-O

A

International classification of diseases for oncology; developed to aid in the collection of information in the field of oncology

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9
Q

SNOMED-CT

A

Systemized nomenclature of medical clinical terminology; is a systemized multi axial and hierarchaly organized nomenclature of medically useful terms

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10
Q

Accreditation

A

Voluntary process of institutional or organizational review in which a quasi-independent body created for this purpose periodically evaluates the quality of the entities work against Preestablished written criteria

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11
Q

Data relevancy

A

Data are useful (quality characteristic)

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12
Q

Data granularity

A

Attributes and values of data defined at correct level of detail for intended use

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13
Q

Data precision

A

Term used describe expected data values

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14
Q

Comorbidity

A

A medical condition that coexist with the primary cause for hospitalization and affects the treatment length of stay

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15
Q

Complication

A

A medical condition that arises during an inpatient hospitalization

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16
Q

POA

A

Present on admission, a condition present at the time of in patient admission

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17
Q

Principal diagnosis

A

The disease or condition that was present on admission, was a principal reason for admission, and receive treatment or evaluation during the hospital stay or visit

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18
Q

Case mix index

A

The average weight of all cases treated at a given facility or by a given position which reflects the resource intensity or clinical severity of a specific group in relation to the groups in the classification system

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19
Q

Source orientated health record

A

Organizes the patient info according to the patient care department that provided the care, grouped together according to their point of origin

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20
Q

Problem orientated records

A

Documentation approach where the physician defines each clinical problem individually and then organizes it into a database problem list. each problem is indexed with a unique number

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21
Q

Integrated orientated health record

A

Organizes all paper forms in strict chronological order and mixes the forms created by different departments. Easy to follow up course of patient’s treatment but is difficult to compare a similar types of information due to format

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22
Q

Integrated record

A

Progress notes of physicians, nurses, therapist and other authorized individuals will be found together in chronological sequence

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23
Q

OASIS

A

A standard for assessment data tool developed to measure the outcomes of patients receiving home health services under the Medicare and Medicaid programs

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24
Point of care charting
Provide context sensitive templates that ensure that the appropriate data are collected and guide users to adhering to professional practice standards
25
Computerized provider OE
Physicians use this for drugs diagnostic studies
26
UHDDS
Uniform hospital discharge date is set. List defines a set of common uniform data elements, used in hospitals
27
UACDS
Uniform ambulatory care data set, includes medical and surgical care provided to patient to depart from the facility on the same day they receive care. Physicians offices medical clinics same-day surgery centers, outpatient hospital clinic and diagnostic departments
28
MDS
Minimum data set, long-term care Medicaid and Medicare services
29
DEEDS
Data elements for emergency departments
30
HEDIS
Health plan employer data and information sets, population-based data
31
TJC
The joint commission. Conducts accreditation service and more than 17,000 healthcare organizations including ambulatory care facilities long-term care facilities behavioral health facilities healthcare networks, MCO's and acute care hospitals
32
Not for profit hospital
Use excess funds to improve their services and to find his education programs and community services
33
For-profit hospitals
Privately owned excess funds are paid back to the managers, owners and investors and form of bonuses and dividends
34
Voluntary hospitals
Not for profit on by and universities, churches, religious orders, unions and other not-for-profit entity
35
Morbidity
The number of sick person's or cases of disease in relationship to a specific population
36
Mortality
Incidence of death in a specific population
37
Integrated healthcare delivery system
Healthcare provider made up of a number of associated medical facilities that furnish coordinated healthcare services. purpose is to organize continuum of care, maximize effectiveness and reduce costs
38
Medical history
Patient's current complaints and symptoms and list his or her past medical personal and family history
39
Physical exam
Position Sussman of the patient's current health status. HEENT
40
EDI
Electronic data interchange. the discrete data from the prescription go directly to the pharmacies information system
41
SOAP notes
S=subjective, patients words o=objective data, factual, lab results A=assessment P=plans, what going to do
42
To promote accuracy, confidentiality and accessibility of health records.
AHIMA's primary fx is
43
1928
HIM was recognized as a allies health profession in
44
A virtual network of AHIMA members for communicating via web based program through a AHIMA. Is only open to members and provides contact for quick problem-solving and support
What is CoP?
45
Current procedural terminology in. Are used to report physician services to the Medicare program to determine reimbursement
What is CPT?
46
American psychiatric Association diagnostic and statistical manual of mental disorders. Glossary of mental disorders
What is DSM-IV-TR?
47
Healthcare common procedure coding system. Collection of codes and descriptions used to represent healthcare procedures supplies products and services
What is HCPCS?
48
International classification of diseases, 9th revision clinical modification. Value one top your list, numerical code to represent diseases and injuries. Volume two alphabetical list for all codes and volume one. Volume three only use the US
ICD-9-CM
49
International classification of diseases 10th revision clinical modification
ICD-10-CM
50
International classification of diseases for oncology; developed to aid in the collection of information in the field of oncology
ICD-O
51
Systemized nomenclature of medical clinical terminology; is a systemized multi axial and hierarchaly organized nomenclature of medically useful terms
SNOMED-CT
52
Voluntary process of institutional or organizational review in which a quasi-independent body created for this purpose periodically evaluates the quality of the entities work against Preestablished written criteria
Accreditation
53
Data are useful (quality characteristic)
Data relevancy
54
Attributes and values of data defined at correct level of detail for intended use
Data granularity
55
Term used describe expected data values
Data precision
56
A medical condition that coexist with the primary cause for hospitalization and affects the treatment length of stay
Comorbidity
57
A medical condition that arises during an inpatient hospitalization
Complication
58
Present on admission, a condition present at the time of in patient admission
POA
59
The disease or condition that was present on admission, was a principal reason for admission, and receive treatment or evaluation during the hospital stay or visit
Principal diagnosis
60
The average weight of all cases treated at a given facility or by a given position which reflects the resource intensity or clinical severity of a specific group in relation to the groups in the classification system
Case mix index
61
Organizes the patient info according to the patient care department that provided the care, grouped together according to their point of origin
Source orientated health record
62
Documentation approach where the physician defines each clinical problem individually and then organizes it into a database problem list. each problem is indexed with a unique number
Problem orientated records
63
Organizes all paper forms in strict chronological order and mixes the forms created by different departments. Easy to follow up course of patient's treatment but is difficult to compare a similar types of information due to format
Integrated orientated health record
64
Progress notes of physicians, nurses, therapist and other authorized individuals will be found together in chronological sequence
Integrated record
65
A standard for assessment data tool developed to measure the outcomes of patients receiving home health services under the Medicare and Medicaid programs
OASIS
66
Provide context sensitive templates that ensure that the appropriate data are collected and guide users to adhering to professional practice standards
Point of care charting
67
Physicians use this for drugs diagnostic studies
Computerized provider OE
68
Uniform hospital discharge date is set. List defines a set of common uniform data elements, used in hospitals
UHDDS
69
Uniform ambulatory care data set, includes medical and surgical care provided to patient to depart from the facility on the same day they receive care. Physicians offices medical clinics same-day surgery centers, outpatient hospital clinic and diagnostic departments
UACDS
70
Minimum data set, long-term care Medicaid and Medicare services
MDS
71
Data elements for emergency departments
DEEDS
72
Health plan employer data and information sets, population-based data
HEDIS
73
The joint commission. Conducts accreditation service and more than 17,000 healthcare organizations including ambulatory care facilities long-term care facilities behavioral health facilities healthcare networks, MCO's and acute care hospitals
TJC
74
Use excess funds to improve their services and to find his education programs and community services
Not for profit hospital
75
Privately owned excess funds are paid back to the managers, owners and investors and form of bonuses and dividends
For-profit hospitals
76
Not for profit on by and universities, churches, religious orders, unions and other not-for-profit entity
Voluntary hospitals
77
The number of sick person's or cases of disease in relationship to a specific population
Morbidity
78
Incidence of death in a specific population
Mortality
79
Healthcare provider made up of a number of associated medical facilities that furnish coordinated healthcare services. purpose is to organize continuum of care, maximize effectiveness and reduce costs
Integrated healthcare delivery system
80
Patient's current complaints and symptoms and list his or her past medical personal and family history
Medical history
81
Position Sussman of the patient's current health status. HEENT
Physical exam
82
Electronic data interchange. the discrete data from the prescription go directly to the pharmacies information system
EDI
83
S=subjective, patients words o=objective data, factual, lab results A=assessment P=plans, what going to do
SOAP notes

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