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RHIT EXAM

PART 2 (T-U)

TermDefinition
Utilization Review Act The federal legislation that requires hospitals to conduct continued-stay reviews for Medicare and Medicaid patients
Utilization review (UR) The process of determining whether the medical care provided to a specific pt is necessary according to pre-established objective screening criteria at time frames specified in the organization's utilization management plan.
Utilization manager (UM) Person that evaluates patient care, ensuring neither underutilization of resources.
Utilization management organization An organization that reviews the appropriateness of the care setting and resources used to treat a pt.
Utilization management (UM) Collection of systems & processes to ensure that facilities & resources, both human & nonhuman, are used maximally & are consistent with pt care needs. Program that evaluates the healthcare facility's efficiency in providing necessary care to pt in the mo
Utilization Patterns of usage for a single medical service or type of service
Utility program A software program that supports, enhances, or expands existing programs in a computer system, such as virus checking, data recovery, backup, and data compression
Usual Fee The amount a physician normally charges the majority of the patients seen for that service
Usual, customary, and reasonable (UCR) charges Method of evaluating providers' fee in which the third-party payer pays for fees that are 'usual' in that provider's practice, 'customary' in the community; and 'reasonable' for the situation
Usual, Customary, and reasonable Type of retrospective fee-for-service payment method in which the third party payer pays for fees that are usual, customary , and reasonable, wherein 'usual' is usual for individual provider's practice, 'customary' means customary for the community, an "r
US Public Health Service An agency of the US Department of Health and human Services that promotes the protection and advancement of physical and mental health
Uses and disclosures Referring to the use and disclosure of a patient's personal health information.
User groups Groups composed of users of a particular computer system
User-based access A security mechanism used to grant users of a system access based on identity
Use, disclosures, and requests 3 types of situations in which personal health information is handled-use, which is internal to a covered entity or its business associate; disclosure, which is the dissemination of PHI from a covered entity or its business associate; and requests for PH
Use case diagram A systems analysis technique used to document a software project from a user's perspective.
Use Case A technique that develops scenarios based on how users will use information to assist in developing information systems that support the information requirements
Understandable, reproducible, and useful (URU Principle) The guiding principle for modeling concepts in SOMED CT, which states that all concepts must be understandable, reproducible, and useful
Uniform Resource Locator (URL) A unique website address that will take the web browser directly to the document located on a web page
Urgent Admission An admission in which the patient requires immediate attention for care and treatment of a physical or psychiatric problem. Generally, the pt is admitted to the first available, suitable accommodation.
Urban area A metropolitan statistical area as defined by the Office of Management and Budget; See core-based statistical area (CBSA)
UPP Urethral pressure profile
Update The annual adjustment to the Medicare fee schedule conversion factor
Upcoding The practice of assigning diagnostic or procedural codes that represent higher payment rates than the codes that actually reflect the services provided to patients: see overcoding
Unstructured data Nonbinary, human-readable data
Unstructured brainstorming method A group problem-solving technique wherein the team leader solicits spontaneous ideas for the topic under discussion from members of the team in a free-flowing and nonjudgemental manner.
Unsecured personal health information (PHI) Personal health information that has been rendered unusable, unreadable, or indecipherable to unauthorized persons.
Unrestricted question aka open-ended question A type of question that allows free-form responses
Unlisted procedure codes Codes available in each section of CPT to describe procedures that have no specific procedure code assigned because the procedure is new or unusual
UNIX An operating system developed by AT and T's Bell laboratories in 1969, and one of the best systems for mission-critical applications.
Universal protocol A written checklist developed by the Joint Commission to prevent errors that can occur when physicians perform the wrong procedure
Universal precautions The application of a set of procedures specifically designed to minimize or eliminate the passage of infectious disease agents from one individual to another during the provision of healthcare services.
Universal personal identifier A concept whereby a unique numerical identifier is assigned to individual recipients of healthcare services in the United States.
Universal patient identifier A personal identifier applied to a patient, such as a number of code, that is used permanently for many and varied purposes.
Universal Medical Device Nomenclature System (UMDNS) A standard international nomenclature and computer coding system for medical devices, developed by ECRI
Universal chart order A system in which the health record is maintained in the same format while the patient is in the facility and after discharge.
Univariate A term referring to the involvement of one variable
Unity of command A human resources principle that assumes that each employee reports to only one specific management position.
Unit work division A method of work organization where each task is performed by one person at the same time that another person is doing a task, but one does not have to wait for the other.
Unit testing The testing step in EHR implementation that ensures that each data element is captures, recorded, and processed appropriately within a given application.
Unit numbering system A health record identification system in which the patient receives a unique medical record number at the time of the first encounter that is used for all subsequent encounters;
Unit labor cost Cost determined by dividing the total annual compensation by total annual oriductivity
Unit filing system A health record filling system in which all inpatient and outpatient visits and procedures are arranged together.
United Nations International Standards Organization (ISO) An international standards organization that coordinates all international standards development
Unique user identifier A unique identifier assigned to all authorized users of the health record and used to track users and log-in procedures.
Unique physician identification number (UPIN) aka National Provider Identifier (NPI) A unique numerical identifier created by the Centers for Medicare and Medicaid Services for use by physicians who bill for services provided to Medicare patients. Discontinued in 2007 and replaced with the NPI.
Unique personal identifier A unique number assigned by a healthcare provider to pt that distinguishes the patient and his or her medical record from all others in the institution, assists in the retrieval of the record, and facilitates the posting of payment
Unique identifier a type of information that refers to only one individual or organization.
Unique identification number A combination of numbers or alphanumeric characters assigned to a particular patient.
Union aka labor organization A collective bargaining until that represents groups of employees and is authorized to negotiate with employers on the employees' behalf in matters related to compensation, health, and safety.
UNII Codes Established name for Active Ingredients and FDA Unique ingredient identifier codes.
Uniform Hospital discharge Data Set (UHDDS) A core set of data elements adopted by the US Department of Health, Education, and Welfare in 1974 that are collected by hospitals on all discharges and all discharge abstract system
Uniformed Services Employment and Reemployment Rights Act (1994) Federal legislation that prohibits discrimination against individuals because of their service in the uniformed services.
Uniform Bill-92 (UB-92) Replaced by the UB-04 in 2007; it was a Medicare form or standardized uniform billing.
Uniform Bill-04 (UB-04) The single standardized Medicare for standardized uniform billing, implemented in 2007 for hospital inpatients and outpatients; this form will also be used by major third party payers and most hospitals
Uniform Ambulatory Care Data Set (UACDS) A data set developed by the National Committee on Vital and Health Statistics consisting of a minimum set of patient-or client-specific data elements to be collected in ambulatory care settings.
Unified modeling language (UML) A common data-modeling notation used in conjunction with object-oriented database design.
Unified messaging The ability for an individual to receive and/or retrieve various forms of messaging at a single access point, including voice, e-mail, fax, and text messages.
Unified Medical Language System (UMLS) Specialist Lexicon English-language lexicon containing biomedical terms.
Unified Medical Language System (UMLS) Semantic Network A categorization of all concepts UMDNS in UMLS Metathesaurus
Unified Medical Language System (UMLS) Metathesaurus A list containing information on biomedical concepts and terms from more than 100 healthcare vocabulaties and classifications, administrative health data, bibliographic and full-text databases, and expert systems.
Unified Medical Language System (UMLS) A program initiated by the National Library of Medicine to build an intelligent, automated system that can understand biomedical concepts, words, & expressions and their interrelationships, includes concepts & terms from many different source vocabularies
Unfreezing The first stage of Lewin's change process in which people are presented with disconcerting information motivated them to change
Unfavorable variance The negative difference between the budgeted amount and the actual amount of a line item, where actual revenue is less than budget or where actual expenses exceed budget
Undercoding a form of incomplete documentation that results when diagnoses or procedures that should be coded are not assigned
Uncontrollable costs costs over which department managers have little or no influence
Unbundling The practice of using multiple codes to bill for various individual steps in a single procedures rather than using a single code that includes all of the steps of the comprehensive procedure.
Unbilled account An account that has not been billd and is not included in accounts receivable
Unbilled Specific report that lists patient encounters that have ended but for whom a final bill has not been prepared.
Unapproved abbreviations policy A policy that defines the abbreviations that are unacceptable for use in the health record.
Unallocated reserves Monies that have not been assigned a specific use
UMLS Terminology Services (UTS) Replaced the UMLS knowledge Source Server (UMLSKS) in December 2010. A tool that provides access to the knowledge Sources and other related resources via the internet.
Ultrasound A diagnostic imaging technique that uses high-frequency, inaudible sound waves that bounce off body tissues. The recorded pattern provides information about the anatomy of an organ.
UDSMR Uniform Data Set for Medical Rehabilitation
UCDS Uniform Clinical Data Set
Types of requests The ways in which requests for access, use, and/or disclosure of patient information are made, which may include mail, telephone, physical presence of the requester, fax, e-mail, or other electronic means.
Type II error A type of error in which the researcher erroneously fails to reject the null hypothesis when it is false
Type I error A type of error in which the researcher erroneously rejects the null hypothesis when it is true.
Type of bill (TOB) A form of coding that represents the nature of each form CMS-1450 claim
Two-tailed hypothesis A type of alternative hypothesis in which the researcher makes no prediction about the direction of the results
Turnkey system aka turnkey product A computer application that may be purchased from a vendor and installed without modification or further development by the user organization .
TTY aka term type Each element of the normalized term in RXNorm
Trojan Horse A destructive piece of programming code hidden in another piece of programming code (such as a macro or e-mail message) that looks harmless.
Trim point Numeric value that identifies atypically long lengths of stay (LOS) or high costs (long-stay outliers and cost outliers, respectively); commonly trim points are plus or minus three standard deviations from the mean
Trigger A documented response that alerts a skilled nursing facility resident assessment instrument assessor to the fact that further research is needed to clarify an assessment
Trier of fact The judge or jury hearing a civil or criminal trial.
TRICARE Standard A TRICARE program that allows eligible beneficiaries to choose any physician or healthcare provider, which permits the most flexibility but may be the most expensive.
TRICARE Senior Prime A managed care demonstration TRICARE program designed to better serve the medical needs of military retirees, dependents, and survivors who are 65 years old and over.
TRICARE Prime Remote A program that provides active-duty service member in the US with specialized version of TRICARE while they are assigned to duty stations in areas not served by the traditional military system.
TRICARE Prime Provides the most comprehensive healthcare benefits at the lowest cost of the three TRICARE options, in which military treatment facilities serve as the principal source of healthcare and a primary care manager is assigned to each enrollee.
TRICARE for Life (TFL) Secondary coverage for TRICARE beneficiaries who become entitled to Medicare Part A.
TRICARE Extra A healthcare program for standard TRICARE beneficiaries in which they can elect to use a civilian healthcare provider from within the regional contractor's provider network. PPO
TRICARE Federal healthcare program that provides coverage for the dependents of armed forces personnel and for retirees receiving care outside military treatment facilities in which the federal government pays a percentage of the cost. Formerly Civilian Health &
Trial Court The lowest tier of state court, usually divided into two courts of limited jurisdiction, which hears cases pertaining to a particular subject matter or involving crimes of lesser severity or civil matters of lower $
Court of general jurisdiction hears more serious criminal cases or civil cases that involve large amounts of money.
Triage The sorting of, and allocation of treatment to, patients. An early assessment that determines the urgency and priority for care and the appropriate source of care.
Treatment, payment, and operations (TPO) Term used in HIPAA Privacy Rule pertaining to broad activities under normal, payment, and operations activities, important because of the rule's many exceptions to release and disclosure of personal health information. Collectively these 3 actions are fun
Treatment guidelines/protocols aka clinical guidelines/protocols
Treatment The manipulation, intervention, or therapy; a broad term used by researchers to generically mean some act, such as a physical conditioning program, a computer training program, a particular laboratory medium, or the timing of prophylactic medication
Traumatic injury A wound or injury included in a trauma registry
Trauma registry software Tracks patients with traumatic injuries from the initial-trauma treatment to death.
Trauma center A hospital that is specially staffed and equipped (usually with an air transport system) to handle trauma patients. They must meet specific criteria for trauma center designation.
Transplantation Putting in or on all or a portion of a living body part taken from another individual or animal to physically take the place and/or function of all or a portion of a similar body part
Transparency The degree to which individual patients are made aware of how their personal health information is or has been dispersed to secondary medical databases.
Transmission standards aka communication standards; messaging standards Standards that support the uniform format and sequence of data during transmission from one healthcare entity to another
Transmission control protocol/internet protocol (TCP/IP) The multifaceted protocol suite, or open standard not-owned by or proprietary to any company, on which the internet runs
Transitional non-facility relative value unit A bend of charge-based relative value units and resource-based relative expense for services provided in a practice setting other than a facility, for example physician's office or freestanding clinic
Transitional facility relative value unit A blend of charge-based relative value units and resource-based relative expense for services provided in a facility.
Transition An ongoing plan used in establishing and maintaining the Medicare fee schedule
Transfusion record health record documentation that includes information on the type and amount of blood products a patient received, the source of the blood products, and the patient's reaction t o them
Transfusion reactions Signs, symptoms, or conditions suffered by a patient as the result of the administration of an incompatible transfusion.
Transformational leadership The leadership of a visionary who strives to change an organization
Transfer record aka referral form A review of the patient's acute stay along with current status, discharge and transfer orders, and any additional instructions that accompanies the patient when he or she is transferred to another facility
Transfer of records The movement of a record from one medium to another (for ex from paper to microfilm or to an optical imaging system) or to another records custodian
Transfer Moving, without taking out, all or a portion of a body part to another location to take over the function of all or a portion of a body part
Transcriptionist A specially trained typist who understands medical terminology and translates physicians' verbal dictation into written reports.
Transcription system System can include voice & text functionality. Used by the transcriptionist to listen to and type the various documents dictated by the physicians. The transcription system should be interfaced with the hospital information system so that the patient name
Transcription The process of deciphering and typing medical dictation.
Transaction standards aka transmission standards Standards that support the uniform format and sequence of data during transmission from one healthcare entity to another.
Transactions Units of work performed against a database management system that are treated in a coherent and reliable way independent of other transaction. A database transaction is atomic, consistent, isolated and durable.
Transaction-processing system aka transactional system A computer-based information system that keeps track of an organization's business transactions through inputs (for ex, transaction data such as admissions, discharges, & transfers In a hospital) & outputs (ex census reports and bills)
Transaction Code Set rule Rule designed to standardize transactions performed by healthcare organization. These standards apply to electronic transactions only; however, paper submissions are similar
Transactional leadership Refers to the role of the manager who strives to create an efficient workplace by balancing task accomplishment with interpersonal satisfaction
Trait approach Proposes that leaders possess a collection of traits or qualities that distinguish them from nonleader
Train-the-trainer A method of training certain individuals who, in turn, will be responsible for training others on a task or skill
Training and development model A 9 step plan designed to help the health information manager or human resources department identify the training needs of an employee group.
Training A set of activities and materials that provide the opportunity to acquire job-related skills, knowledge, and abilities
Trainer A person who gives instruction on a task or skill
Trainee person who is learning a task or skill
Traditional fee-for-service (FFS) reimbursement A reimbursement method involving 3rd party payers who compensate providers after the healthcare services have been delivered; payment is based on specific services provided to subscribers.
Tracer methodology A process the Joint Commission surveyors use during the on-site survey to analyze an organization's system, with particular attention to identified priority focus areas, by following individual patients through the organization's healthcare process in the
Total quality management (TQM) A management philosophy that includes all activities in which the needs of the customer and the organization are satisfied in the most efficient manner by using employee potentials and continuous improvement
Third-party administrator (TPA) An entity that processes healthcare claims and performs related business functions for a health plan.
Total length of stay (discharge days) The sum of the days of stay of any group of inpatients discharged during a specific period of time
Total inpatient service days The sum of all inpatient service days for each of the days during a specified period of time
Total discharge days aka total length of stay
Total billed charges All charges for procedures and services rendered to a patient during a hospitalization or encounter.
Total bed count days The total number of inpatient beds times the total number of days in the period.
Tort Laws State legislation that applies to civil cases dealing with wrongful conduct or injuries
Tort An action brought when one party believes that another party caused harm through wrongful conduct and seeks compensation for that harm.
Topology In networking terms, the physical or logical arrangement of a network
Topography Code that describes the site of origin of the neoplasm & uses the same 3 & 4 character categories as in the neoplasm section of the second chapter of ICD-10
Tonometry Measurement of tension or pressure, especially the indirect estimation of the intraocular pressure, from determination of the resistance of the eyeball to indentation by an applied force.
T1 A digital phone line that can carry data at speeds of up to 1.544 megabits per second
Toll bypass A circumvention of the public telephone toll system to avoid the usage fees charged by public carriers.
Token A session token is a unique identifier which is generated & sent from a server to a software client to identify an interactive session, and which the client usually stores as an HTTP cookie 2. A security token is usually a physical device that an authoriz
TOB aka type of bill
Title Short name of a diagnosis-related group (DRG), such as DRG 1, Craniotomy Age>17 except for trauma
Time period A specific span of dates to which data apply
Timeliness the time between the occurrence of an event & the availability of data about the event. Relates to the use of data. Completion of a health record within timeliness established by legal & accreditation standards & by organizational policy and medical staff
Time ladder A form used by employees to document time spent on various tasks
Timekeeper A performance improvement team role responsible for notifying the team during meetings of time remaining on each agenda item in an effort to keep the team moving forward on its performance improvement project.
Time and motion studies Studies in which complex tasks are broken down into their component motions to determine inefficiencies and to develop improvements.
360-degree evaluation A method of performance evaluation in which the supervisors, peers, and other staff who interact with the employee contribute information
Three-dimensional imaging the construction of pictures generated from computer data in three dimension
Threat The potential for exploitation of a vulnerability. Potential danger to a computer, network, or data
Third-party payment Payments for healthcare services made by an insurance company or health agency on behalf of the insured
Third-party payer An insurance company (Ex BCBS) or healthcare program (Medicare) that pays or reimburses healthcare providers (second party) &/or patients (1st party) for the delivery of medical services.
Third opinion Cost containment measure to prevent unnecessary tests, treatments, medical devices, or surgical procedures
Thin Client A computer with processing capability but no persistent storage (disk memory) that relies on data and applications on the host it accesses to be able to process data.
Therapy threshold The total number of therapy visits (10) for an episode of care in the Medicare system
Therapeutic privilege A doctrine that has historically allowed physicians to withhold information from patients in limited circumstances.
Theory X & Y A management theory developed by McGregor that describes pessimistic and optimistic assumptions about people and their work potential.
Theory A systematic organization knowledge that predicts or explains the behavior or event
Textual A term referring to the narrative nature of much of clinical documentation to date
Text processing aka computer processing of natural language the process of converting narrative text into structured data for computer processing
Text mining the process of extracting and then quantifying and filtering free-text data.
Test statistics A set of statistical techniques that examines the psychometric properties of measurement instruments
Testing the act of performing an examination or evaluation
Tertiary Care Care entered on the provision of highly specialized & technologically advanced diagnostic and therapeutic services in inpatient hospital settings.
Term neonate Any neonate whose birth occurs from the beginning of the first day (267th day) of the 39th week through the end of the last day of the 42nd week (294th day), following onset of the last menstrual period.
Terminology standard a terminology adopted by the standards-setting organizations for use in healthcare
Terminology asset manager This position develops data sets, nomenclatures, and classification standards, and in order to do so the HIM professional must understand the data needs of all stakeholders.
Terminology A set of terms representing the system of concepts of a particular subject field; a clinical terminology provides the proper use of clinical words as names or symbols.
Termination process A HIPAA-mandated process that terminates an employee's access immediately upon separation from the facility
Termination of access An administrative safeguard that is used when an employee changes job position, job roles or duties, or terminates employment with organization
Termination the act of ending something
Terminal-digit filing system A system of health record identification and filing in which the last digit or group of digits (terminal digits) in the health record number determines file placement.
Terminal A term used to describe the hardware in a mainframe-computer system by which data may be entered or retrieved
Ten Step monitoring and evaluation process The systematic an ongoing collection, organization, and evaluation of data related to indicator development promoted by the Joint Commission in the mid-1980s
Temporary privileges Privileges granted for a limited time period to a licensed independent practitioner on the basis of recommendations made by the appropriate clinical department or the president of the medical staff
Temporary National Codes Codes established by insurers when a code is needed before the next January 1 annual update for permanent national codes; these codes are independent of the permanent national codes.
Temporary employee A person who is employed for a temporary, definite period of time, such as to complete a specific project or to fil in for a permanent employee on vacation or other leave; or a person who is employed for an indefinite period of time but who receives none
Temporary budget variance The difference between the budgeted and actual amounts of a line item that is expected to reverse itself in a subsequent period; the timing difference between the budget and the actual event.
Temporary assistance for needy families (TANF) replaced Aid to families with dependent children program A federal program that provides states with grants to be spent on time-limited cash assistance for low-income families, generally limiting a family's lifetime cash welfare benefits to a maximum of five years and permitting states to impose other requireme
Template-based entry A cross between free text and structured data entry. The user is able to pick and choose data that are entered frequently, thus requiring the entry of data that change from patient to patient.
Template A pattern used in computer-based patient records to capture data in a structured manner
Tele-surgery The use of robotics to perform surgery. This allows surgery to be performed on a patient in a different location
Telestaffing aka telecommuting A work arrangement in which at least a portion of the employee's work hours is spent outside the office (usually in the home) and the work is transmitted back to the employer via electronic means
Telephone callback procedures procedures used primarily when employees have access to an organization's health information systems from a remote location that verify whether the caller's number is authorized and prevent access when it is not.
Telemedicine aka telehealth A telecommunication system that links healthcare organizations and transmits text and images for (medical) consultation and treatment
Telematics The use of telecommunications and networks to share information among a patient and healthcare providers located in different locations or sites.
Telecommunications aka voice & data communications
Tax Equity & Fiscal Responsibility Act of 1982 TEFRA
Technology push The view of information technology as being able to push organizations into new business areas. 2. Technology where certain data are pushed or delivered to a particular computer.
Technology management The planning and implementation of technological resources, as needed, to effectively and efficiently carry out the organization's mission
Technical skills one of the three managerial skill categories, related to knowledge of the technical aspects of the business.
Technical safeguard provisions 5 broad categories of controls that can be implemented from a technical standpoint using computer software access controls, audit controls, data integrity, person or entity authentication, and transmission security
Technical component (TC) the portion of radiological & other procedures that is facility based or nonphysician based (ex radiology, films, equipment, overhead, endoscopic suites)
Team recorder/scribe A performance improvement team role responsible for maintaining the records of a team's work during meetings, including any documentation required by the organization
Team norms The rules, both explicit and implied, that determine both acceptable and unacceptable behavior for a group.
Team member A performance improvement team role responsible for participating in team decision making and plan development; identifying opportunities for improvement; gathering, prioritizing, and analyzing data; and sharing knowledge, information, and data that perta
Team leader A performance improvement team role responsible for championing the effectiveness of performance improvement activities in meeting customers' needs and for the content of a team's work.
Team group dynamics Models of team development uniformly define four stages of progression in team group dynamics-cautious affiliation, competitiveness, harmonious cohesiveness, and collaborative teamwork.
Team facilitator A PI team role primarily responsible for ensuring that an effective performance improvement process occurs by serving as advisor and consultant to the PI team; remaining a neutral, nonvoting member; suggesting alternative PI methods and procedures to keep
Team charter A document that explains the issues the team was initiated to address, describes the team's goal or vision, and lists the initial members of the team and their respective departments
Team building The process of organizing and acquainting a team and building skills for dealing with later team processes
Teaching hospital Hospital engaged in an approved graduate medical education residency program in medicine, osteopathy, dentistry, or podiatry
Transaction and code sets (TCS)
Taxonomy The principles of classification system, such as a data classification, and the study of the general principles of scientific classification.
Task analysis A procedure for determining the specific duties and skills required of a job.
Task The step to be performed in order to complete a project or part of a project
Target population A large group of individuals who are the focus of a study
Tactical plan A strategic plan at the level of divisions and department
Tactical decision making A type of decision making that usually affects departments or business units (and sometimes policies and procedures) and includes short- and medium-range plans, schedules, and budget.
Tactic A method for accomplishing an end
Created by: adluch1984
 

 



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