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MOT - 124

Chapter 1 & 3 Test Prep

Accreditation Voluntary compliance with a set of standards developed by an independent agent, who periodically performs audits to ensure compliance.
Activities of daily living refers to self-care, such as bathing, cooking, shopping, and other routines requiring thought, planning, and physical motion.
Acute care facility A facility that provides short-term medical treatment, usually a hospital, for patients having an acute illness or injury or recovering from surgery.
Admission The act of accepting a patient into care in a hospital. Also refers to the status of a patient; requires a physician’s order.
Allied health professionals Health care professionals who care for patients or support patient care in a variety of disciplines, including occupational therapy and physical therapy.
Bed count The actual number of beds that a hospital has staffed, equipped, and otherwise made available for occupancy by patients.
Behavioral health facility Medical facility that focuses on treatment of psychiatric conditions.
Children’s hospital A specialty facility that focuses on the treatment of children.
Conditions of Participation The terms under which a facility is eligible to receive reimbursement from Medicare.
Continuum of care The broad range of health care services required by a patient during an illness or for an entire lifetime. May also refer to the continuity of care provided by a health care organization.
Deemed status The Medicare provision that an approved accreditation is sufficient to satisfy the compliance audit element of the Conditions of Participation.
Diagnosis Literally, “complete knowledge”; refers to the name of the patient’s condition or illness.
Discharge Discharge occurs when the patient leaves the care of the facility. Also refers to the status of a patient. Discharge may be a physician order, against medical advice, or by death
Ethics A system of beliefs about acceptable behavior.
Health information management (HIM) The profession that manages the sources and uses of health information, including the collection, storage, retrieval, and reporting of health information.
Health information technology (HIT) The specialty in the field of health information management that focuses on the day-to-day activities of health information management that support the collection, storage, retrieval, and reporting of health information.
Home health care Health care services rendered in the patient’s home. Also refers to organizations that provide such services.
Hospice Palliative health care services rendered to the terminally ill, their families, and their friends. Also refers to organizations that provide such services.
Hospital An organization having permanent facilities that delivers inpatient health care services through 24-hour nursing care, an organized medical staff, and appropriate ancillary departments.
Inpatients An individual who is admitted to a hospital with the intention of staying overnight.
Integrated delivery system A health care organization that provides services through most or the entire continuum of care.
Licensed beds The maximum number of beds that a facility is legally permitted to have, as approved by state licensure.
Licensure The mandatory government approval required for performing specified activities. In health care, the state approval required for providing health care services.
Long-term care facility A hospital that provides services to patients over an extended period of time; an average length of stay is in excess of 30 days. Facilities are characterized by the extent to which nursing care is provided.
Medical specialty The focus of a physician’s practice, such as pediatrics or oncology. Specialties are represented by Boards, which certify physicians in the specialty.
Mental health facility Medical facility that focuses on treatment of psychiatric conditions.
Nurse Medical professional who has satisfied the academic, professional, and legal requirements to care for patients at state-specified levels.
Outpatient A patient whose health care services are intended to be delivered within 1 calendar day or, in some cases, a 24-hour period.
Palliative care Health care services that are intended to soothe, comfort, or reduce symptoms but are not intended to cure.
Patient care plan The formal directions for treatment of the patient, which involves many different individuals, including the patient.
Physician A medical professional who has satisfied the academic, professional, and legal requirements to diagnose and treat patients at state-specified levels and within a declared specialty.
Primary care physician In insurance, the physician who has been designated by the insured to deliver routine care to the insured and to evaluate the need for referral to a specialist, if applicable. Colloquial use is synonymous with “family doctor.”
Procedure A process that describes how to comply with a policy. Also, a medical or surgical treatment. Also refer to the processing steps in an administrative function.
Psychiatrist A physician who specializes in the diagnosis and treatment of patients with conditions that affect the mind.
Referral The act or documentation of one physician’s request for an opinion or services to another health care professional, often another physician, for a specific patient regarding specific signs, symptoms, or diagnosis.
Rehabilitation facility A health care facility that delivers services to patients whose activities of daily living are impaired by their illness or condition. May be inpatient, outpatient, or both.
Resident A person who after attending college and medical school performs professional duties under the supervision of a fully qualified physician. Also refers to a patient who resides at a Long-term care facility.
Assessment An evaluation. In medical decision making, the physician's evaluation of the subjective and objective evidence. Also refers to the evaluation of a patient by any clinical discipline.
Character A single letter, number or symbol.
Clinical data All of the medical data that have been recorded about the patient's stay or visit, including diagnoses and procedures.
Computerized patient record A digital form of the patient's paper health record.
Data The smallest elements or units of facts or observations. Also refers to a collection of such elements.
Data accuracy The quality that data are correct.
Data collection devices Paper forms or computer screens designed to capture data elements in a standardized format. Also refers to the physical computer hardware or other tool that facilitates the data collection process.
Data dictionary A list of details that describe each field in a database.
Data validity The quality that data reflect the known or acceptable range of values for the specific data.
Demographic data The kind of data used for contacting patient or to distinguish one patient from another.
Epidemiology The study of morbidity (disease) trends and occurrences.
Field A collection or series of related characters. A field may contain a word, a group of words, a number, or a code.
File Numerous records of different types of related data. Files can be large or small, depending on the number of records they contain.
Financial data Elements that describe the payer. For example, the name, address, telephone number, group number, and member number of the patient's insurance company.
Guarantor Responsible party for paying the bill.
Health data Elements related to a patient's diagnosis and procedures as well as factors that may affect the patient's condition.
Health information Organized data that have been collected about a patient or a group of patients. Sometimes used synonymously with the term health data.
Health record (medical record) Contains all of the data collected for an individual patient.
Indicative data Those elements that distinguish one patient from another, such as name, address, and birth date.
Information Data with a frame of reference i.e. processed data.
Integrated record A paper record in which the pages are organized sequentially, in the chronological order in which they were generated.
Objective In the SOAP format from medical decision making, the physician's observations and review of diagnostic tests.
Plan of treatment In the SOAP format for medical decision making, the diagnostic, therapeutic, or palliative measures that are taken to investigate or treat the patient's condition or disease.
Problem-oriented record A paper record with pages organized by diagnosis.
Record A collection of related fields or all of the data collected about a patient’s visit.
Rule out The process of systematically eliminating potential diagnoses.
SOAP format Subjective, Objective, Assessment, and Plan; the medical decision-making process.
Socioeconomic data Elements that pertain to the patient's personal life and personal habits, such as marital status, religion, and culture.
Source-oriented record A paper record in which pages are organized by discipline, department, and/or type of form.
Subjective In the SOAP format from medical decision making, the patient's description of the symptoms or other complaints.
Symptom The patient's report of physical or other complaints, such as dizziness, headache, and stomach pain.
Data becomes _________ once it is organized. Information
A list of ______ with a frame of reference becomes information. data
Items, observations or raw facts are considered what? data
What begins with the absence of disease? Health
What type of controls help prevent errors? Preventative controls
What specialty does the Dr. treat patients who have storng reactions to pollen, insect bites, food, medication, and other irritants. Allertist
What specialty does the Dr. diagnose and treat patients with diseases of the heart and blood vessles. Cardiologist
What specialty does the Dr. administer substances that cuase loss of sensation, particularly during surger. Anesthesiologist
What specialty does the Dr. diagnose and treat patients with skin disorders. Dermatologist
What type of Dr. diagnoses and treats diseases and abnormal conditions of newborns? Neonatologist
The Dr. who provides care to women before, during and after pregnancy is what type of specialist. Obstetrician
What Dr delivers primary health care to children. Pediatrician
Who diagnoses and treats patients with disorders of the mind. Psychiatrist
The Dr. who uses x-rays and other tools to diagnose and treat a variety of diseases is called? Radiologist
What specialty does the Dr. diagnose and treat the reproductive system of women. Gynecologist
Delivers primary health care for patients of all ages. Family Practitioner
Diagnoses/treats diseases of the digestive system Gastroenterologist
Diagnoses/treats disorders of female reproductive system Gynecologist
Who diagnoses/treats cancer Oncologist
Diagnoses/treats diseases of the eye Ophthalmologist
Diagnoses/treats diseases of the muscles and bones Orthopedist
Studies changes in cells, tissue, and organs in order to diagnose diseases and/or to determine possible treatments Pathologist
Support the clinical staff and provide other types of services to a patient. Non-Clinical Professional
These patients would be cared for under a physician’s care over night as “Inpatients” Acute Care Facilities
Patients remain at least overnight and on an average stay less than 30 days Acute Care Facilities
Assigns, collects and reports codes representing clinical data Certified Coding Specialist
Patients are admitted and discharged on the same day also known as “Outpatient” Such as the case of going in for a procedure – Colonoscopy Ambulatory Care Facilities
Ambulatory Surgery – outpatient surgery, same day surgery Ambulatory Care Facilities
“Process of walking” Ambulatory Care Facilities
Inpatients are patients whose evaluation and treatments result in admission to and discharge from a facility on different days Acute Care Facilities
The need for more care than could be given at home. Long-Term Care Facilities
This type of facility provides palliative care. Hospice Facility
Patients remain at least overnight and on average stay longer than 30 days. Long-Term Care Facilities
Differences between long-term care and acute care. Long-Term Care Facilities
The following are examples of what?Physician’s OfficeOutpatient Office Group PracticesClinicAmbulatory SurgeryRadiology and Laboratory Ambulatory Care Facilities
___________ Is an example of demographic information. Address
What organization is responsible for workplace health and safety? OSHA
_______ Is an example of an acute care facility. Hospital
Which organization is known for setting standards in the health care industry. JCAHO - Joint Commision on Accreditation of Healthcare Organizations.
What accrediting body focuses on facilities that provide physical, mental, and occupational rehabilitation services. CARF - Commission on Accreditation of Rehabilitiatiion Facilities.
__________ is responsible for Standards that define how the health care facility should operate in terms of patient care, the clinical flow of data and documentation standards. JCAHO
Which organization is responsible for the Code of Ethics? AHIMA - American Health Information Management Association
Federally funded type of insurance plan for health care for the elderly is what? Mediacare
If you are studying health information managment in college, your program is accredited by___________? CAHIIM - Commission on Accreditation for Health Informatiics and Information Management Education.
To be eligible for reimbursement, a facility must comply with Medicare’s _____________? Conditions of Participation
_________ is an organization, located in Chicago, that sets standards for the health care facilities. JCAHO
Patient are considered “residents". Long-Term Care Facilities
Is an entitlement to health care benefits for persons of advanced age (over 65) or those with certain chronic illnesses Mediacare
Problem summary sheet is part of... POMR
“Nursing Home” Long-Term Care Facilities
___________ is an example of clinical information. Medication
__________ is an example of non-clinical information. Insurance
A Doctor's office is an example of what type of facility? Ambulatory Care Facility
This type of medical record has an index or historical summary of patient care management. Problem list
What type of medical record has everything compiled by category, ex. office visits, lab reports, radiology reports, ect. Source-Oriented
The type of medical record that organizes information by order of date. Integrated Record
units of organized knowledge i.e.… temperatures, pulse, blood pressures or name of patient, disease etc. are called ____________. Data
Data with a frame of reference is called ____. Information
Individual units of knowledge are called ________. Data
All of the data collected on the patient is called____________? a health record or medical record
All of the data must be ___________? accurate, must have validity, must be easily stored/retrieved, organized
____________ are examples of Key Data Categories. Demographic Data, Socioeconomic Data, Financial Data, Clinical Data
List examples of Demographic data. Name and Address,Home/ Work Phone Number, Birth Date, Social Security Number
___________ is the kind of data used for contacting patient or to distinguish one patient from another Demographic Data
Personal data that give clues about potential problems and assistance in planning care are considered what type of data? Socioeconomic Data
Examples of Socioeconomic Data are: Marital Status, Religion, Occupation, Personal Habits, Race/Ethnicity
Responsible party for paying the bill – guarantor is an example of Financial Data
Financial Data Identifies the party responsible for paying the invoice.
____________ are examples of Clinical Data. Diagnosis, Temperature, Blood Pressure, Pulse, Respiration, Medications, Lab and X-ray Reports
Data specific to the patient’s diagnosis and treatment is called? Clinical Data
The physician sees patient, examines, and develops an opinion about the disease or condition. This what part of SOAP Subjective
Physical exam, tests maybe recommended such as labs, x-rays, MRI, EKG. This is what part of a SOAP Note? Objective
Once the diagnosis is made, the patient may be referred to another specialty physician, such as a Cardiologist for a consult. This is what part of SOAP Assessment
The physician assessed the patient and make a plan for future evaluations or plan of treatment. This is what part of SOAP Plan
"I'm having dizzy spells and have not been taking my BP med." Belongs in what part of SOAP? Subjective
BP 170/110 both arems, lying down, sitting & standing; weight 202#. Belongs in what part of SOAP? Objective
Hypertension - Belongs in what part of SOAP? Assessment
Rx for Norvasc 5 mg daily; to onitor BP and return in1 week for Bp check; placed on 1200 calorie diet to lose 20#. Belongs in what part of SOAP? Plan
Patient calling for appointment - What kind of data is needed? Name, Telephone number, Current patientInsurance, Reason for visit
Patient Arrives at the Office - What kind of data is needed? Registration Form for patient to fill out with info such as name, address, responsible person, patient history any changes etc. If new patient, create a new folder.
Medical Assistant Taking Vitals - what data should the MA collect? Weight, Height, Temp, Blood PressureRes/Pulse, Symptoms/How long
60mg pseudoephedrine every 4 hours; 100 mg Tylenol as needed - is a example of what? Plan
Acute sinusitis with pharyngitis - is an example of what? Assessment
Patient complaints of headache - is an example of what? Subjective
Patient’s frontal sinuses sensitive to percussion; lungs clear, throat slightly inflamed - is an example of what? Objective
Each data is organized from date of first visit Integrated Record
All data is grouped together by information, such as, progress notes, lab, x-ray, surgeries, consults Source-Oriented Record
Advantage – Useful when the need to know when events happen in relation to each other Integrated Record
All of the patient’s diagnosis data are organized together, such as all diagnosis pertaining to appendicitis, or the patient’s heart problem Problem-Oriented Record
Advantage – Easily comparable Source-Oriented Record
Disadvantage – retrieval or comparison is difficult, would have to know exactly when an event or procedure happened to retrieve Integrated Record
Disadvantage – Complicated to file Source-Oriented Record
Advantage – useful when the patient has several chronic conditions that are addressed at different visits Problem-Oriented Record
Disadvantage – Complicated and duplication of data may be necessary so that laboratory reports related to different problems are included in all relevant sections Problem-Oriented Record
Integral part of a Problem-Oriented Record Patient Summary Sheet/List
Advantage – Versatility, all data is linked to one patient by a medical record number, solve filing and retrieval inefficiencies Electronic Health Record
Disadvantage – Cost Electronic Health Record
Same rule applies to data collected on paper or electronically. “Garbage In, Garbage Out”
_______ reminds the user of which data must be be collected. A form
The _________ ensure that complete data are collected according to the clinical guidelines of the facility and of the profession and according to regulation forms
All forms must be in compliance with ____________ and __________ standards (JCAHO) with signature upon whom completed licensure, accreditation
Created by: kbcanarr