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Chapter 1

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Abstracting   after the coding function is completed, this is performed to enter codes and other pertinent information (patient identification data, admission/discharge dates, and so on) utilizing computer software  
Accreditation   A voluntary process that a health care facility or organization(hospital) undergoes to demonstrate that it has met standards beyond those required by law  
ACGME-accreditation council for graduate medical education   has not used the term intern since 1975. It uses the word resident (although they still complete an internship)  
Active   Delivers most hospital medical services, performs significant organizational and administrative medical staff duties  
Agenda   The listing of all items of business to be discussed  
American Recovery and Reinvestment Act   authorized an expenditure $1.5 billion in grants for construction, renovation, and equipment and for the acquisition of health information technology services  
Associate   Advancement to active category is being considered  
Biometrics   An identifier that measures a borrower's unique physical characteristic or behavior and compares it to a stored digital tempplate to authenticate the identiy of the borrowwer, such as fingerprints, hand or face geometry , a retinal scan, or handwritten si  
Governing Board (Board of trustees, Board of governors, board of directors)   serves without pay, and its membership is represented by professionals from the business community  
Bylaws rules and regulations   Procedures based on federal and state regulations, and accreditation standards, which clarify claws  
CMS- Centers for medicare & medicaid services   In 2001 Replaced the HCFA (health care financing administration.  
Chief resident   Is a physician who is in their final year of residency or in the year after the residency has been completed. Plays a significant administrative or teaching role in guiding new residents  
CFR- code of federal regulation   IS the codification of the general and permanent rules published in the Federal Register by the executive departments and agencies of the federal government  
Coding   Involves assigning numeric and alphanumeric codes to diagnoses, procedures, and services (performed by CCS, CPC, RHIT)  
Consulting   includes highly qualified practitioners available as consultants when needed  
Continuum if care   A complete range of programs and services, with the type of of health care indicating the health care services provided  
Contract services   Facilities use these for health information services in addition to general services. Such as housekeeping, medical waster disposal, and clinical services sucj as physical therapy, emergency care and speech pathology. PURPOSE is to improve quality while c  
Courtesy   Admits an occasional patient to the hospital;  
CPT- Current procedural terminology   Published annually by the AMA and codes are 5 digit numbers assigned to ambulatory procedures and services  
Deemed status   Accreditation hospitals have met or exceeded Conditions of Participants to participate in the Medicare and Medicaid programs  
Deeming authority   Means that an accrediting organizations standards have met or exceeded CMS's Conditions of participation for Medicare certification, acceredited facilities are eligible for reimbursement under Medicare and Medicard and CMS is less liekly to conduct an on  
Deficit reduction act of 2005   Created the MIP (Medicaid Integrity Program), which is a fraud and abuse detection program  
Digital signature   Type of electronic signature(uses public key cryptography)  
Disaster recovery plan   Ensures an appropriate response to internal and externaldisasters  
DNR- do not resuscitate   Instructs edical and nursing staff to not try to revive the patient if breathing or heartbeat stops. It is documented in the patients medical record by the physician  
EHR- electronic health record   An automated, accessible record that contains multimedia data (digital, scanned images, voice video and so on)  
Electronic signature   Encompasses all technology options available that can be used to authenticate a document  


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Created by: s.fitzpatrick410 on 2013-02-18

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