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HIT Chapter 3

Essentials of Health Information Management

TermDefinition
Activity of Daily Living (ADL) Include bathing, dressing, eating, toileting, walking, and so on.
Acute Care Facility (ACF) Is a hospital that provides health care services to patients who have serious,sudden,or acute illnesses or injuries and/or who need certain surgeries.
Administration for Children and Families (ACF) Is responsible for programs that provide services and assistance to needy children and families, including TANF.
Administration of Aging (AOA) Supports a nationwide aging network, providing services to the elderly to enable them to remain independent.
Adult Day Care Provides care and supervision in a structured environment to seniors with physical or mental limitations.
Agency for Healthcare Research and Quality (AHRQ) Supports research designed to improve the outcomes and quality of health care, reduce its costs, address patient safety and medical errors, and broaden access to effective services.
Agency for Toxic Substance and Disease Registry (ATSDR) Works with the states and other federal agencies to prevent exposure to hazardous substances from waste sites.
Alzheimer's Treatment Facilities/ Dementia Care Facilities Many same characteristics as ALF, there is more extensive monitoring of residents and day to day care.
Ambulatory Care / Outpatient Care Allows patients to receive care in one day without the need for inpatient hospitalization.
Ambulatory Patients/ Outpatients Are treated and released the same day and do not stay overnight. (max time 24hr 59min and 59 seconds)
Ambulatory Surgical Center (ASC) Surgery is provided on an outpatient basis at a free standing ambulatory surgical center. Patients arrive day of procedure, undergo surgery in an OR and recover under the nursing staff.
Ambulatory Surgery Patient Undergo certain procedures that can be performed on an outpatient basis, with the patient treated and released the same day (max 24hr 59min 59 seconds)
Ancillary Services Are diagnostic and therapeutic services provided to inpatients and outpatients (labs,physical therapy)
Assisted- Living Facility (ALF) Is a combination of housing and supportive services including personal care and household management for seniors.
Bed Count/Bed Size Is the total number of inpatient beds for which the facility is licensed by the state.
Behavioral Health Care Hospital Specialize in treating individuals with mental health diagnoses.
Bureau of Prisons (BOP) Provides necessary medical, dental, and mental health to inmates by a professional staff and consistent with acceptable community standards.
Capitation Payment Lump sum paid by the HMO to care for a group of subscribers.
Centers of Disease Control and Prevention (CDC) Provides a system of health surveillance to monitor and prevent outbreak of diseases.
Chemical Dependency Program Provides 24 hour medically directed evaluation and withdrawal management in an acute care inpatient setting.
Chemothrapy Intravenous administration of chemical agents that have specific and toxic effects upon a disease-causing cell or organism.
Clinical Laboratory Performs testing in microbiology, clinical chemistry and toxicology (Stand alone clinic)
Clinic Outpatient Receives scheduled diagnostic and therapeutic care (chemo following an inpatient stay)
Closed- Panel HMO Includes group and staff models that provide services at owned health care centers or satellite clinics,or by physicians who belong to a specially formed medical group that serves the HMO.
Continuing Care Retirement Communities (CCRC) Provide different levels of care based on the resident's needs from independent living apartments to skilled nursing care in an affiliated nursing facility.
Copayment Is a fixed amount a subscriber must pay when seeking health care services.
Correctional Facilities Provide inmates with a secure housing environment that also offers vocational and educational advancement.
Crisis Services Provides short-term (usually fewer than 15 days) crisis intervention and treatment
Critical Access Hospital (CAH) Are located more than 35 miles from any other hospital or CAH ; or they are are state certified as being a necessary provider of health care to area residents. (Raduius shortned to 15 miles for where only secondardy roads are availble or mountainous terra
Curative Care Therapeutic
Day Treatment Program Intensive treatment program provided to patients who live in the community but come to clinic up to 5 days per week.
Developmentally Disabled/Mentally Retarded Facilities These facilities provide residential care and day programming, including academic training, clinical and technical assistance, health care service, and diagnosis and evaluation of individuals with developmental disabilities.
Diagnosis-Related Groups (DRGs) Classifies inpatient hospital cases into groups that are expected to consume similar hospital resources
Direct Contract Model HMO Individual physicians in the community deliver contracted health care services to subscribers.
Drug Therapy Intravenous administration of other drugs including antibiotics,antivirals, and so on.
Durable Medical Equipment (DME) Includes: canes, crutches, IV supplies, Hospital beds, Ostomy supplies, oxygen, Prostheses, walkers, wheelchairs.
Emergency Care Patient Are treated for urgent problems (trauma)and are either released the same day or admitted to the hospital as inpatients.
Exclusive Provider Organization (EPO) Provides benefits to subscribers who receive health care services from network providers.
Family Practioners Provide care to the entire family and focus on general medicine, obstetrics, pediatrics,and geriatrics.
Family Support Services Services are provided to assist families in caring for the patent (support group).
Federal Medical Centers (FMCs) Provide major medical care within the Bureau of Prisons (BOP)
Food and Drug Administration (FDA) Assures the safety of food, cosmetics, and the safety and efficacy of pharmaceutical
General Hospitals Provide emergency car, perform general surgery, and admit patients for range of problems ( fractures,heart disease)based on licensing by the state.
Group Model HMO Participating physicians who are members of an independent multi-specialty group provide health care services.
Group Practice Without Walls (GPWW) Managed care contract in which physicians maintain their own offices and share services with plan members.
Health Maintenance Organizations (HMO) An alternative to traditional health insurance coverage; provide comprehensive health care services to members on a prepaid basis.
Health Resources and Services Administration (HRSA) Provides health resources for medically undeserved populations, work to build the health care workforce, maintains the National Health Service Corps, oversees the nation's organ transplantation system, works to decrease infant mortality and improve child
Heart and Vascular Center Provides ambulatory cardiovascular services to include diagnosis and treatment, disease prevention, research, education, and cardiac rehabilitation.
Home Care Allows people who are seriously ill or dying to remain at home and receive treatment from nurses, social workers, therapist, and other licensed health care professionals who provide skilled care in the home.
Hospitalists Are physicians who spend most of their time in a hospital setting admitting patients to their inpatient services from local primary care providers.
Hospital-Owned Physician Practice Are at least partially owned by the hospital, and the physicians participate in a compensation plan provided by the hospital.
Hydration Therapy Intravenous administration of fluids, electrolytes, and other additives.
Imaging Center Freestanding facility that provides radiographic and other imaging services (MRI,PET) to ambulatory patients.
Indian Health Service(IHS) Supports a network of 37 hospitals, 60 health centers, 3 school health centers, 46 health stations and 34 urban Indian health centers to provide services to nearly 1.5 million American Indians and Alaska Natives of federally recognized tribes.
Individual/ Independent Practice Association (IPA) Physicians who remain in their independent office settings provide health care services to subscribers.
Industrial Health Clinic Located in a business setting (factory), the emphasis is on employee health and safety.
Infusion Center/ Ambulatory Infusion center (AIC) Freestanding center that dispenses and administers prescribed medications by continuous or intermittent infusion to ambulatory patients.
Inpatients Stay overnight in the facility for 24 or more hours and are provided with room, board, and nursing services.
Integrated Delivery System (IDS) An organization of affiliated provider sites that offer joint health care services to subscribers.
Integrated Provider Organization (IPO) Manages health care services provided by hospitals, physicians, and other health care organizations.
Intensive Case Management Specially trained individuals coordinate and/ or provide mental health health, financial, legal, and medical services to help the patient live successfully at home and in the community.
Intermediate Care Facility (ICF) Provides developmentally disabled people with medical care and supervision, nursing services, occupational and physical therapies, activity programs,educational and recreational services and psychological services.
Internal Medicine Physicians Specialize in the care of adults.
Long-Term Care Includes a range of nursing, social,and rehabilitative services for people who need ongoing assistance.
Long-Term Care Hospital (LTCH) Is defined in Medicare law as a hospital that has an average inpatient length of stay greater than 25 days.
Long-Term Hospital Classification Average LOS of greater than 25 days.
Managed Care Originally referred to the prepaid health care sector (HMO), which combined health care delivery with the financing of health care services.
Management Service Organization (MSO) Provides practice management services, including administrative and support services,to individual physician practices.
Medical Foundation Nonprofit organization that contracts with and acquires the clinical and business assets of physicians practices.
Medical Necessity Requires the documentation of services or supplies that are proper and needed for the diagnosis or treatment of a medical condition.
Military Health System (MHS) Administers health care for active members of the uniformed service and their dependents as provided by military treatment centers.
Military Medical Support Office (MMSO) Coordinates civilian health care services when MTF services are unavailable.
Military Treatment Facility (MTF) Is a clinic/hospital located on a US base.
Multi-Hospital Systems Two or more hospitals owned,managed, or leased by a single organization; may include acute, long-term,pediatric, rehabilitation, and/or psychiatric care facilities.
Multi-Specialty Group Physician Practices Offer various types of medical specialty care in one organization, and they may be located in more than one location.
National Commission on Correctional Health Care (NCCHC) Was established in the 1970s to provide an external peer review process for correctional institutions that wish to meet its national accepted Standards for health service.
National Institutes of Health (NIH) With 17 separate institutes is the worlds premier medical research organization, supporting some some 35,000 research projects nationwide in diseases like Cancer, Alzheimer's disease, diabetes, arthritis, heart ailments, and AIDS.
Neighborhood Health Center Heath care is provided to the economically disadvantaged, and treatment is family-centered because illness may result indirectly from crowded living conditions,unsanitary facilities, and other socioeconomic factors.
Network Model HMO Two or more physician multi-specialty group practices to provide contracted health care services to subscribers.
Network Providers Which are physicians and health care facilities under contract to the managed care plan.
Newborn Patients Receive infant care upon birth and if necessary they receive neonatal intensive care either within the hospital or as the result of transfer to another hospital.
Observation Patients Receive services furnished on a hospital's premises that are ordered by a physician or other authorized individual, including use of a bed and periodic monitoring by nursing or other staff, which are reasonable and necessary to evaluate an outpatients co
Open-Panel HMO Includes direct contract, individual practice association, and network models.
Outpatient Clinic Patients receive follow-up mental health care, and visits are usually under one hour.
Pain Management Intravenous administration of narcotics and other drugs designed to relieve pain.
Pain Management Center Specializes in treatment of acute and chronic pain syndromes using proven medications and procedures.
Palliative Care Comfort management.
Partial Hospitalization Program Program for hospital patients who regularly use the hospital facilities for a substantial number of either daytime or nighttime hours (behavioral health, geriatric, rehabilitative care)
Pediatricians Provide comprehensive services for infants, children, and adolescents.
Personal Care and Support Services Which provide assistance in performing daily living activities, such as bathing, dressing, grooming, going to the toilet, mealtime assistance, travel training, and accessing recreation services.
Physician-Hospital Organization (PHO) Managed care contracts are negotiated by hospitals and physician groups.
Point-of-Service Plan (POS) Patients have the freedom to use an HMO panel of providers (for which co payment is paid)or to self-refer to non HMO providers(greater out of pocket expenses apply)
Preadmission Certification (PAC) Is a form of utilization management that involves the review for medical necessity of inpatient care prior to inpatient admission.
Preferred Provider Organization (PPO) A network of physicians and hospitals join together to contract with third party (insurance companies), employers, and other organizations to provide health care to subscribers for a discounted fee.
Primary Care Center Offers adult and family care medicine in internal medicine, pediatrics, and family practice.
Public Health Services (PHS) Commissioned Corps is 1 of 7 Uniformed Services of the US and provides highly trained and mobile health professionals who carry out programs to promote the nations health, understand and prevent diseases,injury, assure safe and effective drugs and medical
Public Health Department Provides preventive medicine services such as well baby clinics, which include immunizations and routine checkups.
Referred Outpatient Receives diagnostic (lab test) or therapeutic care (physical therapy) because such care is unavailable in the primary care provider's office.
Rehabilitation Facility (Outpatient) Provides occupational, physical, and speech therapy to patients with orthopedic injuries, work-related injuries, sports related injuries, and various neurological and neuromuscular conditions.
Rehabilitation Hospital (Inpatient) Admit patients who are diagnosed with trauma (car wreck) or disease (stroke) and need to learn how to function.
Residential Care Facility (RCF) Provides non-medical custodial care, which can be provided in a single family residence, a retirement residence, or in any appropriate care facility including a nursing home.
Residential Treatment Facility Seriously disturbed patients receive intensive and comprehensive psychiatric treatment on a long-term basis.
Respite Care Care is provided by specially trained individuals at a setting other than the patient's home to offer relief and rest to primary caregivers.
Satellite Clinics Ambulatory care centers that are established remotely from the hospital.
Short-Term (Acute) Hospital Classification Average length of stay (LOS) is 4-5 days and a total of less than 25 days.
Single Hospitals Self contained hospital, not part of a larger organization
Single-Specialty Group Physician Practices Consists of two or more physicians who provide patients with one specific type of care (primary care).
Skilled Care Includes services that are ordered by a physician and provided under the supervision of a registered nurse or physical, occupational, or speech therapist.
Skilled Nursing Facility (SNF)/ Nursing Facility Provides medically necessary care to inpatients on a daily basis that is performed by, or under the supervision of, skilled medical personnel.
Solo Physician Practices Do not have physician partners or employment affiliations with other practice organizations.
Specialty Hospitals Concentrates on a particular population (children) or disease category (cancer)
Staff Model Health Maintenance Organization (HMO) Similar to large, multi-specialty group practices, it may be partially owned by the physician employees, with the physicians typically functioning as employees of either the physician group owning the practice or the insurer.
Student Health Center Provides health care to full and part time students who become ill or injured.
Subacute Care Is provided in hospitals that provide specialized long term acute care such as chemo, injury rehab, ventilator,support, wound care, and other types of health care services provided to seriously ill patients.
Subscribers Individuals who pay premiums.
Substance Abuse and Mental Health Services Administration (SAMHSA) Works to improve the quality and availability of substance abuse prevention, addiction treatment, and mental health services.
Swing Bed Criteria allow a rural hospital to admit a nonacute care patient
Temporary Assistance to Needy Families (TANF) Is the new state-federal welfare program.
Therapeutic Group Home 6-10 individuals are provided with supervised housing (may be linked to day treatment program).
Total Parenteral Nutrition (TPN) Administration of nutritional substance by peripheral or central intravenous infusion to patients who are either already malnourished of have the potential for developing malnutrition.
Triple Option Plan / Cafeteria Plan/ Flexible Benefit Plan Provides subscribers and employees with a choice of HMO, PPO, or traditional health insurance plans.
Urgent Care Center / Emergency Care Center Immediate care is provided by an on-duty physician.
Utilization Management Controls health care costs and the quality of health care by reviewing cases for appropriateness and medical necessity.
Ventilator Breathing machine
Veterans Health Administration (VHA) An agency in the department of Veteran Affairs, provides medical, surgical, and rehabilitation care to veterans of the armed services.
Veterans Integrated Service Network (VISN) Administer and provide health care services at VA medical centers (VMAC) and community-based outpatient clinics.
Home Infusion Care is also provided by home health care agencies when intravenous administration of medication is medically appropriate for the patient's condition, and treatment is administered in the home instead of on an inpatient hospital basis.
Hospice Care Provides comprehensive medical and supportive social, emotional, and spiritual care to terminally ill patients and their families.
Federal Certification Measure the ability of health care facilities to deliver care that is safe and adequate, in accordance with federal law and regulations.
Center for Medicare and Medicaid Services (CMS) Administers medicare, medicaid , and Childrens Health Insurance Program (CHIP) and was formerly called the Health Care Financing Administration (HCFA)
Created by: smercantini6890