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RHIT
| Term | Def |
|---|---|
| Zone Program Integrity Contractor (ZPIC) | A CMS program that replaces the Medicare Program Safeguard Contractors (PSC). Are responsible for detection and prevention of fraud, waste, and abuse across all Medicare claim types by performing medical reviews, data analysis, and auditing. |
| Zip | A computer utility that combines two or more files into one and reduces the size of the file. |
| Zero-based budgets | Types of budgets in which each budget cycle poses the opportunity to continue or discontinue services based on available resources so that every department or activity must be justified and prioritized annually to effectively allocate resources. |
| Zero balance | The result of writing off the balance of an account, which closes off the account and ends the days in accounts receivable. |
| Years of schooling | The highest grade of schooling completed by the enrollee or patient. |
| Y-axis | The vertical axis on a graph that displays frequency. |
| X12N | A subcommittee of X12 that defines EDI standards for the insurance industry, including healthcare insurance |
| X12 | An ANSI-accredited group that defines EDI standards for many American industries, including healthcare insurance. Most of the electronic transaction standards mandated or proposed under HIPAA are X12 standards. |
| Extensible Markup Language (XML) | A standardized computer language that allows the interchange of data as structured text. |
| X-axis | The horizontal axis on a graph where the independent variable are noted. |
| Web Services Architecture (WSA) | an architecture that utilizes web-based tools to permit communication among different software applications. |
| Write-off | The action taken to eliminate the balance of a bill after the bill has been submitted and partial payment has been made or payment has been denied and all avenues of collecting the payment have been exhausted. |
| Wound Repair | Refers to three types of repair-simple, which refers to the repair of superficial wound, involving primarily epidermis or dermis or subcutaneous tissues without significant involvement of deeper structures; |
| intermediate wound repair | which involves the repair of wounds that require layered closure of one or more of the deeper layers of subcutaneous tissues and superficial (non-muscle) fascia, in addition to the skin (epidermal and dermal) closure |
| Complex wound repair | designates the repair of wounds requiring more than layered closures, namely, scar revision, debridement, extensive undermining, stents, or retention sutures. |
| WORM Technology | Write once, read many. The use of this technology prevents the user from altering what is stored, but the data can be viewed as many times as necessary. |
| Worm | A special type of computer virus, usually transferred from computer to computer via e-mail, that can replicate itself and use memory but cannot attach itself to other programs. |
| World Wide Web (www) | A global network of networks offering services to users with web browsers. |
| World Organization of Family Doctors (Wonca) | the organization instrumental in the development of the International Classification of Primary Care; formerly called the World Organization of National Colleges, Academics, and Academic Associations of General Practitioners/family Physicians |
| World Health Organization (WHO) | The United Nations specialized agency created to ensure the attainment by all peoples of the highest possible levels of health; responsible for a number of international classifications, including the ICD10 and ICF |
| Workstation | A computer designed to accept data from multiple sources in order to assist in managing information for daily activities and to provide a convenient means of entering data as desired by the user at the point of care. |
| Working Conditions | The environment in which is performed (surroundings) and the physical dangers or risks involved in performing the job (hazards). |
| Workers' Compensation | The medical and income insurance coverage for certain employees in unusually hazardous jobs. |
| Worker Immaturity-Maturity | The model developed by Argyris to describe how leadership should change with an employee's maturity. |
| Workers' Adjustment and Retraining Notification (WARN) Act | Federal legislation that requires employers to give employees a 60-day notice in advance of covered plant closings and covered mass layoffs. |
| Workaround | A temporary alternate process created as a substitute until a more permanent solution is found. |
| Work Schedules | The process by which facility managers ensure that each department has adequate personnel to properly complete all assigned tasks. |
| Work Sampling | A work measurement technique that uses random sample measurements to characterize the performance of the whole. |
| Work Products | Documents produced during the completion of a task that may be a component of, or contribute to, a product deliverable. |
| Work Measurement | The process of studying the amount of work accomplished and how long it takes to accomplish work in order to define and monitor productivity. |
| Work Imaging Study | A technique used to analyze the time required of full-time equivalent employees (FTE) compared with established productivity standards. |
| Workgroup on Electronic Data Interchange (WEDI) | A subgroup of Accreditation Standards Committee X12 that has been involved in developing electronic data interchange standards for billing transactions. |
| Workforce Trends | Referring to changes that will likely take place in the workforce in the future. |
| Workforce Members | Employees, volunteers, trainees, and other persons who work under the direct control of HIPAA-covered entity, regardless of whether they are paid by the covered entity. |
| Workforce | Under the HIPAA Privacy Rule, employees, volunteers, trainees, and other persons whether paid or not who work for and are under the direct control of the covered entity. |
| Workflow technology | Technology that automatically routes electronic documents into electronic in-baskets of its department staff for disposition decisions. |
| Workflow analysis | A technique used to study the flow of operations for automation aka operation analysis. |
| Workflow | Any work process that must be handled by more than one person. |
| Work division | The way in which tasks are handled within an organization. |
| Work Distribution chart | A matrix that depicts the work being done in a particular workgroup in terms of specific tasks and activities, time spent on tasks, and the employees performing the tasks. |
| Work distribution analysis | An analysis used to determine whether a department's current work assignments and job content are appropriate. |
| Work breakdown structure | A hierarchical structure that decomposes project activities into levels of detail. |
| Work and Data flow Analyst | The work and data flow analyst must be able to study the flow of data into the system and its associated processes and look for ways to improve it, using data flow diagrams and other tools to document the various flows of data within the facility. |
| Work | The effort usually described in hours, needed to complete a task. |
| Physician work (WORK) | Component or element of the (RVU) that should cover the physician's salary. This work is the time the physician spends providing a service and the intensity with which that time is spent. |
| Physician work 4 elements | of intensity are mental effort & judgement,technical skill, physicial effort, and psychological stress. |
| Wonca International Classification Committee (WICC) | the current name of the Wonca Classification Committee, the group that designed the International Classification of Primary Care |
| Wireless local-area network (WLAN) | A wireless local-area network that uses radio waves as the carrier |
| Withhold Pool | Aggregate amount withheld from all providers' capitation payments as an amount to cover expenditures in excess of targets. |
| Withhold | Portion of providers' capitated payments that managed care organizations deduct and hold. in order to create an incentive for efficient or reduced utilization of healthcare services; also called physician contingency reserve. |
| Wireless wide-area network (WWAN) | network that uses mobile telecommunication cellular network technologies to connect computers across a large area. |
| Wireless Technology | A type of technology that uses wireless networks and wireless devices to access and transmit data in real time. |
| Wireless on wheels (WOWs) | Notebook computers mounted on carts that can be moved through the facility by users. |
| Wired Equivalent Privacy (WEP) | a form of encryption used to authenticate the sender and receiver of messages over networks, particularly when the internet is involves in the data transmission; should provide authentication (both sender and recipient are known to each other), data secur |
| Wide-area network (WAN) | A computer network that connects devices across a large geographical area |
| Whole number | Any of the set of non-negative integers. It cannot be a fraction, decimal, percentage, or negative number. |
| Western Blot test | A blood test used to diagnose infection with human immunodeficiency virus (HIV) |
| Well newborn | a newborn born at term, under sterile conditions, with no diseases, conditions, disorders, syndromes, injuries, malformations, or defects diagnosed, and no operations other than routine circumcisions performed. |
| Weight | The numerical assignment that is part of the formula by which a specific dollar amount, or reimbursement, is calculated for each diagnosis-related group or each ambulatory payment classification. |
| Web Services architecture (WSA) | an architecture that utilizes web-based tools to permit communication among different software applications. |
| Web Services | An open, standardized way of integrating disparate, web browser-based and other applications. |
| Web Portal Technology | A website entryway serving as a starting point to access, find, and deliver information and including a broad array of resources and services, such as e-mail, forums, and search engines. |
| Web Portal | A website entryway through which to access, find, and deliver information. |
| Webmasters | Individuals who support web applications and the healthcare organization's intranet and Internet operations |
| Web-enabled technology | an application that was originally written for a client or server or mainframe environment that is rewritten to be accessed through a web browser. |
| Web content management systems | Systems in which information placed on a website can be labeled and tracked so that it can be easily located, modified, and reused. |
| Web browser-based system aka web browser-based or web native architectures | Systems and applications written in one or more web programming languages |
| Web-based training | instruction via the internet that enables individuals to learn in a structure that is self-paced and self-directed while interacting and collaborating with other students and the instructor via a conferencing system. |
| Web-based systems and applications | Systems and applications that use internet technology. |
| Web appliance | A computer without secondary storage capability that is designed to connect to a network. |
| Waiver of privilege | An exception to physician-pt privilege that occurs when a party claims damages for a mental or physical injury; the party thereby waives his or her right to confidentiality to the extent that it is necessary to determine whether the mental or physical in |
| Waiver aka advance beneficiary notice (ABN) | A statement signed by the pt when he or she is notified by the provider, prior to a service or procedure being done, that Medicare may not reimburse the provider for the service, wherein the patient indicates that he will be responsible for any charges. |
| Waiting Period | Time between the effective date of a healthcare insurance policy and the date the healthcare insurance plan will assume liability for expenses related to certain health services, such as those related to pre-existing conditions. |
| Wage index | Ratio that represents the relationship between the average wages in a healthcare setting's geographic area and the national average for that healthcare setting. Wage Indexes are adjusted annually and published in the Federal Register |
| Vulnerability | An inherent weakness or absence of a safeguard that could be exploited by a threat |
| V/Q | Ventilation-perfusion |
| VPN (Virtual private network) | An encrypted funnel through the internet that enables secure transmission of data. |
| Voluntary Review | An examination of an organization's structures and processes conducted at the request of a healthcare facility seeking accreditation from a reviewing agency. |
| Voluntary Disclosure Program | A program unveiled in 1998 by OIG that encourages healthcare providers to voluntarily report fraudulent conduct affecting Medicare, Medicaid, and other federal healthcare programs. |
| Volume logs | Forms used (sometimes in conjunction with time ladders) to obtain information about the volume of work units received and processed in a day |
| Voir Dire | The process of jury selection. |
| VoIP (Internet protocol technology) | A type of communications technology that allows people to initiate real-time calls through the internet instead of the public telephone system. |
| Vocational Rehabilitation | The evaluation and training aimed at assisting a person to enter or reenter the labor force. |
| Vocabulary Standards aka controlled vocabulary | A list or collection of clinical words or phrases with their meanings; also the set of words used by an individual or group within a particular subject field, |
| Vocabulary mapping process | a process that connects one clinical vocabulary to another |
| VLBW | Very low birth weight |
| Vitrectomy | An ocular surgical procedure involving removal of the soft jelly-like material (vitreous humor) that fills the area behind the lens of the eye () & replacement with a clear solution. This is necessary when blood and scar tissue accumulate in the vitreous |
| Vital statistics | Data related to births, deaths, marriages, and fetal deaths. |
| Visit | A single encounter with a healthcare professional that includes all of the services supplied during the encounter. |
| Vision Statement | Short description of an organization's ideal future state. |
| Vision | A picture of the desired future that sets a direction and rationale for change |
| Virus | A computer program, typically hidden, that attaches itself to other programs and has the ability to replicate and cause various forms of harm to the data. |
| Virtual Reality (VR) | An artificial form of reality experienced through sensory stimuli and in which the participant's actions partly affect what happens. |
| Virtual private network (VPN) | An encrypted tunnel through the internet that enables secure transmission of data |
| Virtual HIM | Health information management function that takes place outside of a traditional office setting. |
| Videoconferencing | A communications service that allows a group of people to exchange information over a network by using a combination of video and computer technology. |
| Veterans Health Administration | The component of the US Department of Veterans Affairs that implements the medical assistance program of the VA |
| Vertical Structure | The levels and relationship among positions in an organizational hierarchy |
| Vertically Integrated System aka integrated provider organization (IPO) | An organization that manages the delivery of healthcare services provided by hospitals, physicians (employees of the IPO), and other healthcare organizations (ex nursing facilities) |
| Vertical dyad linkage aka leader-member exchange | Micro theory that focuses on dyadic relationships, or those between two people or between a leader and a small group; explains how in-group and out-group relationships form with leader or mentor, and how delegation may occur. |
| Version Control | The process whereby a healthcare facility ensures that only the most current version of a patient's health record is available for viewing, updating, and so forth. |
| Verification Service | An outside service that provides a primary source check on information that a physician makes available on an application to the medical staff |
| Verification | act of proving or disproving the subject matter or documents in question or comparing an activity, a process, or a product with the corresponding requirements or specifications |
| Vendor System | A computer system developed by a commercial company not affiliated with the healthcare organization |
| Vendors | Companies that provide products and/or services to healthcare organizations. Depending upon access to protected health information (PHI), the vendor may or may not be categorized as a business associate |
| Vector graphic data aka signal tracing data | Digital data that have been captured as points and are connected by lines (a series of point coordinates) or areas (shapes bounded by lines) |
| V codes | A set of ICD-9-CM codes used to classify occasions when circumstances other than disease or injury are recorded as the reason for the patient's encounter with healthcare providers. |
| Value-based purchasing (VBP) | CMS incentive that links payments more directly to the quality of care provided and rewards providers for delivering high-quality & efficient clinical care. Incorporates clinical process-of-care measures as well as measures from the hospital consumer asse |
| Vaginal birth after previous cesarean delivery | (VBAC) |
| Vascular order | The furthest point to which the catheter is placed into the branches of a vessel originating off the aorta, vena cava, or vessel punctured if the aorta is not entered, and is referred to the level of selectivity |
| Vascular Family | A group of blood vessels that is fed by a branch, or primary division, of a major blood vessel. |
| Variance Analysis | An assessment of a department's financial transactions to identify differences between the budget amount and the actual amount of a line item. |
| Variance | A disagreement between 2 parts; the square of the standard deviation; a measure of variability that gives the average of the squared deviations from the mean; in financial management, the difference between the budgeted amount and the actual amount of a |
| Variable costs | Resources expended that vary with the activity of the organization, for ex, medication expenses vary with pt volume. |
| Variable | A characteristic or property that may take on different values |
| Variability | The dispersion of a set of measures around the population mean |
| Values statement | A short description that communicates an organization's social and cultural belief system. |
| Value set | a collection of concepts drawn from one or more vocabulary code systems and grouped together for a specific purpose. |
| Value-based leadership | an approach that emphasizes values, ethics, and stewardship as central to effective leadership |
| Valuation | The estimated market value of a project, an object, a merger, and so on |
| Validity | The extent to which data correspond to the actual state of affairs or that an instrument measures what it purports to measure. A test ability to accurately & consistently measure what it purports to measure |
| 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 |
| System Testing | A type of testing performed by an independent organization to identify problems in information Systems. |
| System Thinking | An objective way of looking at work-related ideas and processes with the goal of allowing people to uncover ineffective patterns of behavior and thinking and then finding ways to make lasting improvements |
| System theory | An interdisciplinary field of study that analyzes and describes how any group of objects work together to produce a result |
| System development life cycle (SDLC) | A model used to represent the ongoing process of developing (or purchasing) information systems |
| Systems analyst aka Clinical systems analyst | An individual who investigates, analyzes, designs, develops, installs, evaluates, and maintains an organization's healthcare information systems; is typically involved in all aspects of the systems development life cycle; & serves as a liaison among end u |
| Systems analysis | Process of studying organizational operations and determining information systems requirements for a given application. |
| Systems | The foundations of caregiving, which include buildings (environmental services), equipment (technical services), professional staff (human resources), and appropriate policies (administrative) |
| System planning and analysis | The first phrase of the systems development life cycle |
| System maintenance & evaluation | The final phrase of the systems development life cycle. |
| System infectors aka boot-record infector | Computer viruses that infect the system areas of diskettes or the hard drive of a computer |
| System implementation | The third phrase of the systems development life cycle. |
| System design | The second phrase of the systems development life cycle. |
| System Catalog | An integrated data dictionary (which is a component of a database management system) that generally contains information on data tables and relationship in addition to data definitions. |
| System Build | The creation of data dictionaries, tables, decision support rules, templates for data entry, screen layouts, and reports used in a system. |
| Systematized Nomenclature of Medicine Clinical Terminology (SNOMED CT) | A concept-based terminology consisting of more than 110,000 concepts with linkages to more than 180,000 terms with unique computer-readable codes |
| Systematized Nomenclature of Human and Veterinary Medicine (SNOMED) | A comprehensive clinical vocabulary developed by the College of American Pathologists, which is the most promising set of clinical terms available for a controlled vocabulary for healthcare |
| Systematized Nomenclature of Dentistry (SNODENT) | A systemized nomenclature of dentistry containing dental diagnoses, signs, symptoms, and complaints |
| Systematic Sampling | The process of selecting a sample of subjects for a study by drawing every nth unit on a list. |
| Systematic literature review aka integrative review; meta-analysis | Methodical approach to literature review that reduces the possibility of bias; characterized by explicit search criteria to identify literature, and inclusion and exclusion criteria to select articles and information sources, and evaluation against consis |
| System | A set of related and highly interdependent components that are operating for a particular purpose. |
| Syntax | The comparable structure or format standards of data, usually as they are being transmitted from one system to another, for systems to exchange data or talk to one another, they syntax must be made the same |
| Synergy | The interaction of parts to produce a greater outcome than would be obtained by the parts acting separately |
| Synchronous | Occurring at the same time |
| Swing beds | Hospital-base acute-care beds that may be used flexibly to serve acute or skilled nursing care |
| Severity weight (SW) | A factor developed by 3M to indicate relative severity within every level in APR-DRGs and used to improve comparisons in profiling by severity-adjusted raw statistics |
| Survey tools | Research instruments that are used to gather data and information from respondents in a uniform manner through the administration of a predefined and structured set of questions and possible responses. |
| Survey team | A group of individuals sent by an accrediting agency (usually the Joint Commission) to review a healthcare organization for accreditation purposes |
| Survey Feedback | An organizational development technique in which data on practices and attitudes are gathered and participants interpret them in order to plan change |
| Survey | A method of self-report research in which the individuals themselves are the source of the data |
| Surgical specialties | A group of clinical specialties that concentrates on provision of surgical service by physicians who have received advanced training in a special field ex obgyn, opth, ortho, cardio |
| Surgical review | Evaluation of operative and other procedures, invasive and noninvasive using the Joint Commission guidelines |
| Surgical procedure | Any single, separate, systematic process upon or within the body that can be complete in itself; is normally performed by a physician, dentist, or other licensed practitioner. |
| Surgical package aka global package | A global package for surgical procedures that refers to the payment policy of bundling payment for the various services associated with a surgery into a single payment covering professional services for preoperative care, the surgery itself & postoperativ |
| Surgical operation | One or more surgical procedures performed at one time for one patient via a common approach or for a common purpose |
| Surgical death rate aka postoperative death rate | The ratio of deaths within 10 days after surgery to the total number of operations performed during a specified period of time |
| Surgery | An umbrella term referring to the procedures of incision, excision, amputation, introduction, endoscopy, suture, and manipulation |
| Supreme Court | The highest court in the US legal system; hears cases from the US courts of appeals and the highest state courts when federal statues, treaties, or the US Constitution is involved |
| Supply Management | Management and control of the supplies used within an organization |
| Supplemental Medical insurance (SMI) | A small independent insurance policy that consumers may take out independently of their primary insurance that helps pay for physicians' services, medical services, and supplies not covered by Medicare Part A |
| Supplement | Putting in or on biological or synthetic material that physically reinforces and/or augments the function of a portion of a body part. The body part may have been taken out during a previous procedure, but is not taken out as part of the supplement proced |
| Supervisory Manager | Managers who oversee small (2-10 person) functional workgroups or teams and often perform hands-on functional workgroups or teams and often perform hands-on functions in addition to supervisory functions. |
| Supervisory management | management level that oversees the organization's efforts at the staff level and monitors the effectiveness of everyday operations and individual performance against pre-established standards |
| Supercomputer | The largest, fastest, and most expensive type of computer that exists today. |
| Superbill | The office form used for physician office billing that is initiated by the physician and states the diagnoses and other information for each encounter |
| Summons | An instrument used to begin a civil action or special proceeding and is a means of acquiring jurisdiction over a party. |
| Summary list aka problem list | A list of illnesses, injuries, and other factors that affect the health of an individual patient, usually identifying the time of occurrence or identification and resolution |
| Successor | A task in a dependency relationship between two tasks that is dependent on the predecessor task |
| Substance Abuse and Mental Health Services Administration (SAMHSA) | A division of the Department of Health and Human Services which in 2004 published a document explaining the relationship between HIPAA and the Alcohol and Drug Abuse Regulations regarding confidentiality and release of information |
| Subscriber aka certificate holder, insured; member; policyholder | Individual or entity that purchases healthcare insurance coverage |
| Subrogation | The means by which an insurance company recovers moneys from third party; that amount paid to or on behalf of an insurer, usually sought in respect to a loss (for ex accident or injury |
| Subpoena Policy | A policy that outlines the steps required to handle subpoenas and e-discovery requests |
| Subpoena Duces Tecum | A written order commanding a person to appear, give testimony, and bring all documents, papers, books, and records described in the subpoena. The devices are used to obtain documentation during pretrial discover and to obtain testimony during trial |
| Subpoena ad testificandum aka subpoena | A command to appear at a certain time and place to give testimony on a certain matter |
| Subject matter jurisdiction | Pertaining to district courts, jurisdiction to hear cases involving felonies and misdemeanors that fall under federal statues. |
| Subcutaneous mastectomy | The removal of breast tissue, leaving the skin of the breast and nipple intact. This type of mastectomy usually requires that breast implant be inserted. |
| Subacute care | A type of step-down care provided after a patient is released from an acute-care hospital (including nursing homes and other facilities that provide medical care, but not surgical or emergency care) |
| Student membership | AHIMA membership category for students enrolled in an AHIMA-accredited or approved program |
| Structure measures | Indicators that measure the attributes of the healthcare setting (ex adequacy of equipment and supplies) |
| Structure indicators | Quality indicators that measure the attributes of an organizational setting such as number and qualifications of staff, adequacy of equipment and facilities, and adequacy of organizational policies and procedures. |
| Structured question | Close-ended question, which is used more for self-assessments, web-based or e-mail surveys, or mailed and faxed surveys |
| Structured query Language (SQL) | A fourth-generation computer language that includes both DDL and DML components and is used to create and manipulate relational databases |
| Structured Interview | An interview format that uses a set of standardized questions that are asked of all applicants |
| Structured input (SI) | Information that has been organized to allow identification and separation of the context of the information from its content. |
| Structured decision | A decision made by following a formula or a step-by-step process |
| Structured data entry aka discrete data | A type of healthcare data documentation about an individual using a controlled vocabulary rather than narrative text |
| Structured data | Binary, computer-readable data |
| Structured Brainstorming | A group problem-solving technique wherein the team leader asks each participant to generate a list of ideas for the topic under discussion and then report them to the group in a nonjudgmental manner |
| Structured analysis | A pattern identification analysis performed for a specific task |
| Structure and content standards | Common data elements and definitions of the data elements to be included in an electronic patient record. |
| Structure | A term from Donabedian's model of quality assessment that assesses an organization's ability to provide services in terms of both the physical building and equipment and the people providing the healthcare services. The foundations of caregiving, which in |
| Stress testing | Testing performed toward the end of EHR implementation to ensure that the actual number, or load, of transactions that would be performed during peaks hours can be performed. |
| Streaming Video aka motion video aka framed data | A medium for storing, manipulating and displaying moving images in a format, such as frames, that can be presented on a computer monitor |
| Stratified random sampling | The process of selecting the same percentages of subjects for a study sample as they exist in the subgroup (strata) of the population. |
| Strategy map | A visual representation of the cause-and-effect relationships among the components of an organization's strategy. |
| Strategy | A course of action designed to produce a desired (business) outcome |
| Strategic planning | A disciplined effort to produce fundamental decisions that shape and guide what an organization is, what it does, and why it does it |
| Lifetime Reserve days | Inpatient hospital care is limited to 90 days in each benefits period. When a beneficiary exhausts the 90 days, a non-renewable reserve of 60 days of additional care can be used. |
| Strategic Plan | The document in which the leadership of a healthcare organization identifies the organization's overall mission, vision, and goals to help set the long-term direction of the organization as a business entity |
| Strategic management | The art and science of formulating, implementing, and evaluating cross-functional decisions that enable an organization to achieve its objectives |
| Strategic issue | A question, topic, opportunity, or concern that is addressed through strategic management. |
| Strategic information system (IS) planning | A process for setting IS priorities within an organization; the process of identifying and prioritizing IS needs based on the organization's strategic goals with the intent of ensuring that all IS technology initiatives are integrated and aligned with the |
| Strategic goals | Long-term objective set by an organization to improve its operation |
| Strategic decision support system aka decision support system (DDS) | A computer-based system that gathers data from a variety of sources and assists in providing structure to the data by using various analytical models and visual tools in order to facilitate and improve the ultimate outcome in decision-making tasks associa |
| Strategic decision making | A type of decision making that is usually limited to individuals, such as boards of directors, chief executive officers, and top-level executives, who make decisions about the healthcare organization's strategic direction. |
| Strategic communications | Programs created to advance specific organizational goals such as promoting a new center or service, establishing a new program, or positioning the organization as a center of excellence in a specific discipline such as cardiology or oncology. |
| Straight numeric filing system | A health record filing system in which health records are arranged in ascending numerical order. |
| Storytelling | A group process technique in which group members create stories describing the plausible future state of the business environment. |
| Storyboard | A graphic display tool used to communicate the details of performance improvement activities; a type of poster that includes text and graphics to describe and illustrate the activities of a PI project |
| Storming | The second of four steps that occur when creating a functional team, storming occurs when individual team members examine their role within the group. |
| Storage management software | Software used to manage the SAN, keep track of where data are stored, and move older data to less expensive, but still accessible, storage location |
| Storage area network (SAN) | Storage devices organized into a network so that they can be accessible from any server in the network |
| Storage and retrieval | A healthcare facility's method for safely and securely maintaining and archiving individual patient health records for future reference |
| Stop-loss insurance | A form of reinsurance that provides protection for medical expenses above a certain limit |
| Stop-loss benefit | Specific amount, in certain time frame such as one year, beyond which all covered healthcare services for that policyholder or dependent are paid at 100 percent by the healthcare insurance plan |
| Stimulus aka | American Recovery & Reinvestment Act of 2009 |
| Stillbirth | The birth of a fetus, regardless of gestational age, that shows no evidence of life (such as heartbeats or respirations) after complete expulsion or extraction from the mother during childbirth |
| Step-down unit | A unit used for cardiac patients for care between the cardiac intensive care unit and a general medical or surgical unit |
| Step-down allocation | A budget concept in which overhead costs are distributed once, beginning with the area that provides the least amount of non-revenue-producing services. |
| Stem and Leaf plot | A visual display that organizes data to show its shape and distribution, using two columns with stem in the left-hand column and all leaves associated with that stem in the righ-hand column; the "leaf" is the ones digit of the number, and the other digits |
| Stealth virus | A type of computer virus that attempts to hide itself by concealing its presence in infected files |
| Stay outliers aka outlier | A case in a prospective payment system with unusually long lengths of stay or exceptionally high costs (day outlier or cost outlier, respectively). An extreme statistical value that falls outside the normal range. |
| Statutory law aka legislative law | Written law established by federal and state legislatures |
| Statue of limitations | A specific time frame allowed by a statute or law for bringing litigation |
| Statute | A piece of legislation written and approved by a state or federal legislature and then signed into law by the state's governor or the president. |
| Statistics | A branch of mathematics concerned with collecting organizing, summarizing, and analyzing data. |
| Statistical significance | The probability that an observed difference is due to chance |
| Statistical inference | Helps to make inference or guess about a larger group of data by drawing conclusions from a small group of data |
| Statistical process control chart | A type of run chart that includes both upper and lower control limits and indicates whether a process is stable or unstable. |
| State workers' compensation insurance funds | Funds that provides a stable source of insurance coverage for work-related illnesses and injuries and serve to protect employers from underwriting uncertainties by making it possible to have continuing availability of workers' compensation coverage. |
| State of work (SOW) aka project charter | A document that defines the scope and goals of a specific project |
| Statement of stockholder's equity aka statement of fund balance | A statement detailing the reasons for changes in each stockholder's equity accounts |
| Statement of revenue and expenses aka earning report, income statement, profit and loss statement, statement of operations. | A financial statement showing how much the organization makes or loses during a given reporting period |
| Statement of retained earnings | A statement expressing the change in retained earnings from the beginning of the balance sheet period to the end |
| Statement of changes in net assets | The accounting statement that explains the differences in net assets from period to period on the balance sheet |
| Statement of changes in financial position aka statement of cash flow | A statement detailing the reason why cash amounts changed from one balance sheet period to another |
| Statement | A list of unpaid involves; sometimes a cumulative list of all transactions between purchaser and vendor during a specific time period |
| State Children's Health Insurance Program (SCHIP) aka The Children's Health insurance program or CHIP | The children's healthcare program implemented as part of the Balanced Budget Act of 1997 |
| Star Schema | A visual method of expressing multidimensional data structure in a relational database |
| Standing orders | Orders the medical staff or an individual physician has established as routine care for specific diagnosis or procedure |
| Standing committees | Committees that are put in place to oversee ongoing and cross-functional issues (ex QI committee, medical staff committee, infection control committee). |
| Standard vocabulary | A vocabulary that is accepted throughout the healthcare industry |
| Standard treatment protocols (STPs) aka special treatment procedure | Protocols that identify the specific service units necessary to produce a given product (patient) |
| Standards for privacy of individually identifiable health information aka Privacy Rule | The federal regulations created to implement the privacy requirements of the simplification subtitle of the health Insurance Portability and Accountability Act of 1996; effective in 2002; afforded pt certain rights to and about their PHI |
| Standards development organization (SDO) | A private or government agency involved in the development of healthcare informatics standards at a national or international level. |
| Standard risk | A person who, according to an insured's underwriting standards, is entitled to purchase insurance without paying an extra premium or incurring special restrictions. |
| Standard of care | An established set of clinical decisions and actions taken by clinicians and other representatives of healthcare organizations in accordance with state and federal laws, regulations, and guidelines; codes of ethics published by professional associations o |
| Standard normal distribution aka normal distribution | Most of the values in a set of data are close to the 'average' and relatively few values tend to one extreme or the other, creating a bell-shaped curve |
| Standardized payment | National base amount in the inpatient rehabilitation facility prospective payment system (IRF PPS). This amount is multiplied with relative weight of the case-mix group to calculate the unadjusted payment; published annually in the Federal Register |
| Standard generalized `up language (SGML) | An international standards organization standard that establishes rules for identifying elements within a text document. |
| Standard federal rate | National base payment amount in the prospective payment system for long-term care hospitals (PPS for LTC). This amount is multiplied with the relative weight of the long-term care diagnosis-related group (LTC-DRG) to calculate the unadjusted payment. Publ |
| Standard deviation | A measure of variable that describes the deviation from the mean of a frequency distribution in the original units of measurement; the square root of the variance |
| Standard cost profile (SCP) | A set of data that identifies, analyzes, and defines the activities, including the costs, of departments within the organization to produce a service unit. |
| Standard | A scientifically based statement of expected behavior against which structures, processes, and outcomes can be measured. |
| Stakeholder | A individual within the company who has an interest in, or is affected by the results of a project |
| Staging System | A method used in cancer registers to identify specific and separate different stages or aspects of the disease. |
| Stages of grief | 5 stage model created by Kubler-Ross describing how people progress through loss to acceptance in response to death that may be applied to similar changes experienced by employees in response to organizational transition. The five stages are shock and den |
| Stage of the neoplasm | A classification of malignancies according to the anatomic extent of the tumor, such as primary neoplasm, regional lymph nodes, and metastases. |
| Staff retention | The process of keeping valued employees on the job and reducing turnover. |
| Staff model health maintenance organization aka closed panel | A type of health maintenance that employs physicians to provide healthcare services to subscribers |
| Staffing structure | The arrangement of staff positions within an organization |
| Staffing analysis | Study performed to determine the most efficient and cost-effective staff mix. |
| Staff authority | The lines of reporting in the organizational chart in which the position advises or makes recommendations |
| Stable monetary unit | The currency used as the measurement of financial transaction |
| SSN aka Social security number | A unique numerical identifier assigned to every US citizen |
| SSA aka | Social Security Administration |
| Sponsor | A person or an entity that initiates a clinical investigation of a drug (usually the drug manufacturer or research institution that developed the drug) by distributing it to investigators for clinical trials; a person in an organization that supports, pro |
| Splitter vocabulary | A type of vocabulary that permits storage of each concept in a sample narrative. ex SNOMED |
| Split percentage payment | A type of reimbursement in which payments are made for each episode period, and home health agencies receive two payments to make up the total permissible reimbursement for the episode. |
| Clinical Special Product Label (SPL) | A LOINC standard that provides information found in the approved FDA drug label or package insert in a computer-readable format for use in electronic prescribing and decision support |
| Spirometry | The measurement of the breathing capacity of the lungs |
| Spin-off | A new, separate company formed by a parent company and whose shares are distributed to existing shareholders of the parent company in proportion to the new entity's relationship to the parent company. |
| Speech recognition technology | Technology that translates speech to text |
| Speech recognition | Situation where speech is converted to text on a screen |
| Speech-language therapy (SLP) | A treatment intended to improve or enhance the resident's ability to communicate and/or swallow |
| Specimen | Tissue submitted for individual and separate attention, requiring individual examination and pathologic diagnosis |
| Specified low-income Medicare beneficiaries (SLMBs) | Medicare beneficiaries who have resources similar to qualified Medicare beneficiaries, but higher incomes, although still less than 120 percent of the federal poverty level |
| Specialty software | A type of applications software that performs specialized, niche functions such as encoding or drawing and painting |
| SPECIALIST Lexicon | A tool that supplies the lexical information needed for the Specialist natural language processing (NLP) system |
| Special-cause variation | An unusual source of variation that occurs outside a process but affects it |
| Special care unit | A medical care unit in which there is appropriate equipment and a concentration of physicians, nurses, and other who have special skills and experience to provide optimal medical care for critically ill patients or continuous care of patients in special d |
| Span of control | Concept of classical organization theory that suggests managers are capable of supervising only a limited number of employees |
| Spaced training | The process of learning a task in sections separated by time |
| Source system | A system in which data was originally created. Independent information system application that contributes data to an EHR, including departmental clinical applications (ex lab IS) and specialty clinical application (ex IC) |
| Source-oriented health record format | A system of health record organization in which information is arranged according to the patient care department that provided the care. |
| Source of truth | The official source of information that will be used for legal purposes for a particular request for information. |
| Source of admission code | Required code for Medicare that indicates the admission source. |
| Source of admission | The point from which a patient enters a healthcare organization, including dr referral, clinic referral, hmo referral, transfer from a hospital, TSNF, TAHF, ED Referral, court or law enforcement referral, an delivery of newborns |
| Sound data aka real audio data | The storing, manipulating, and displaying of sound in a computer-readable format |
| Solvency | The state of being able to pay all debts |
| Solo practice | A practice in which the physician is self-employed and legally the sole owner |
| Sole proprietorship | A venture with one owner in which all profits are considered the owner's personal income |
| Sole-community hospital | Hospital that by reason of factors such as isolated location, weather conditions, travel condition, or absence of other hospitals (determined by HHS), is the sole source of pt hospital services reasonable available to individuals in a geographical area wh |
| Severity of illness (SOI) system | A database established from code data on diseases and operations and used in the hospital for planning and research purposes |
| Software as a Service (SaaS) | Software that is provided through an outsourcing contract and is deployed over the internet |
| Software | A program that directs the hardware components of a computer system to perform the tasks required |
| Signature on file | (SOF) |
| Social Security Act of 1935 | The federal legislation that originally established the Social Security program as well as unemployment compensation and support for mothers and children, amended in 1965 to create the Medicare and Medicaid programs |
| Socialization | The process of influencing the behavior and attitudes of a new employee to adapt positively to the work environment |
| SOAPIER | A form of charting narrative notes that requires subjective, objective, assessment, plan, intervention, evaluation, and revision in the note structure. |
| SOAP | An acronym for a component of the problem-oriented medical record that refers to how each note contains documentation relative to subjective observation, objective observations, assessments, and plans |
| Snowflakes Schema | A modification of the stay schema in which the dimension tables are further divided to reduce data redundancy. Used in data warehouses |
| Sniffers | A software security product that runs in the background of a network, examining and logging packet traffic and serving as an early warning device against crackers. |
| Skilled nursing facility prospective payment system (SNF PPS) | A per-diem reimbursement system implemented in July 1998 for costs (routine, ancillary, and capital) associated with covered skilled nursing facility services furnished to Medicare Part A beneficiaries |
| SNF market basket index aka | skilled nursing facility market basket index |
| SNF aka semantic normal form or skilled nursing facility | A long-term care facility with an organized professional staff and permanent facilities (including inpatient beds) that provides continuous nursing and other health-related, psychosocial, and personal services to patients who are not in an acute phrase of |
| Smart card | A credit card-sized piece of plastic embedded with a computer chip that stores information and incorporates security features. |
| Sliding scale | A method of billing in which the cost of healthcare services is based on the patient's income and ability to pay. |
| Skin graft | Skin tissue that is completely detached from its blood supply in the donor area and reattached to a blood supply from the case of the wound or the recipient area. |
| Skill | The ability, education, experience, and training required to perform a job task |
| Skewness | The horizontal stretching of a frequency distribution to one side or the other so that one tail is longer than the other, creating a negative or positive skew. |
| Sixty-day episode payment | The basic unit of payment under the home health prospective payment system that covers a beneficiary for 60 days regardless of the number of days furnished unless the beneficiary elects to transfer, has a significant change in condition, or discharge and |
| Six Sigma | Disciplined and data-driven methodology for getting rid of defects in any process |
| Site visit | An in-person review conducted by an accreditation survey team; the visit involves document reviews, staff interviews an examination of the organization's physical plant, and other activities |
| Single sign-on | A type of technology that allows a user access to all disparate applications through one authentication procedure, this reducing the number and variety of passwords a user must remember and enforcing and centralizing access control. |
| Single-blinded study | A study design in which (typically) the investigator but not the subject knows the identity of the treatment and control group. |
| Simultaneous equations methods | A budgeting concept that distributes overhead costs through multiple iterations, allowing maximum distribution of interdepartmental costs among overhead department |
| Simulation observation | A type of nonparticipant observation in which researchers stage events rather than allowing them to happen naturally |
| Simulation and inventory modeling | The key components of a plan that are computer simulated for testing and experimentation so that optimal operational procedures can be found. |
| Simulation | A training technique for experimenting with real-world situation by means of a computerized model that represents the actual situation |
| Simple random sampling | The process of selecting units from a population so that each one has exactly the same chance of being included in the sample. |
| Simple payback method | A method used to justify a proposed capital expenditure where the asset cost is divided by the net annual income of the asset to determine how long it will take for the asset to 'pay back' what it cost the organization |
| Simple complete mastectomy | The removal of all of the breast tissue without removing lymph nodes or muscles |
| Simon's decision-making model | A model proposing that the decision-making process moves through three phases-intelligence, design, and choice |
| Sign-on bonus | A monetary incentive used by a facility to encourage a candidate to accept employment |
| Significant procedure ambulatory payment classification | A procedure that constitutes the reason for the visit dominates the time and resources rendered during the visit, and is not subject to payment reduction or discounting |
| Significant procedure | A procedure that is surgical in nature or carries a procedural or an anesthetic risk or requires specialized training |
| Significant change in condition (SCIC) adjustment | A single episode payment under multiple home health resource groups, each prorated to the number of service days delivered |
| Significance level | The criterion used for rejecting the null hypothesis; a pre-established cutoff that determines whether the null hypothesis is rejected; the alpha level |
| Signal tracing data aka vector graphic data | Digital data that have been captured as points and are connected by lines (a series of point coordinates) or areas (shapes bounded by lines) |
| Short stay patient | A patient admitted to the hospital for an intended stay of less than 24 hours and who is considered an outpatient and not included in inpatient hospital census statistics |
| Short stay outlier | Hospitalization that is five-sixth of the geometric length of stay for the long-term care diagnosis related group |
| Shift rotation | The assignment of employees to different periods of service to provide coverage, as needed |
| Shift differential | An increased wage paid to employees who work less-desirable shifts, such as evenings, nights, or weekends. |
| Sheltered employment | An employment category provided in a special industry or workshop for the physically, mentally, emotionally, or developmentally handicapped. |
| Shaving | The sharp removal, by transverse incision or horizontal slicing, of epidermal and superficial dermal lesions without a full-thickness dermal excision; includes local anesthesia and chemical or electrocauterization of the wound; wound does not require sutu |
| Shareware | A type of software that can be tried before being purchased |
| Shared Visions-New Pathways | The new accreditation process implemented by the Joint Commission in January 2004, and designed to focus on systems critical to the safety and quality of patient care treatment, and services |
| Shared system | Systems developed by data-processing companies in the 1960s and 1970s to address the computing needs of healthcare organizations that could not afford or chose not to purchase, their own mainframe computing system |
| SF | straightforward |
| Severity-of-illness (SI) screening criteria | Standards used to determine the most appropriate setting of care based on the level of clinical signs and symptoms that a patient shows upon presentation to a healthcare facility |
| Severity of illness adjustment aka risk adjustment aka case-mix adjustment | Any method of comparing the severity of illness of one group of patients with that of another group of patients |
| Severity indexing | The process of using clinical evidence to identify the level of resource consumption. A method for determining degrees of illness. |
| Service utilization domain | The range of available services including the patient's use of inpatient services preceding home care admission and the receipt of rehabilitation therapies during the home health episode. |
| Service-line coder | A person who excels in coding one particular service line such as oncology or cardiology |
| Service Level Agreement (SLA) | A contract between a customer and a service provider that records the common understanding about service priorities, responsibilities, guarantees, and other terms, especially related to availability, serviceability, performance, operation, or other attrib |
| Service bonus | A monetary reward given to long-term staff in recognition of their skills and commitment to the organization |
| Service | An act performed by a person on behalf of another person. The means by which a defendant is notified a lawsuit. |
| Server redundancy | Situation where two servers are duplicating effort |
| Server | A type of computer that makes it possible to share information resources across a network of client computers |
| Serial-unit numbering system | A health record identification system in which patient numbers are assigned in a serial manner but records are brought forward and filed under the last number assigned |
| Serial numbering system | A type of health record identification and filing system in which patients are assigned a different but unique numerical identifier for every admission |
| Serial filing system | A health record identification system in which a patient receives sequential unique numerical identifiers for each encounter with, or admission to, a healthcare facility |
| Sequence diagram | A system analysis tool for documenting the interaction between an actor and the information system |
| Somatosensory evoked potential (SEP) test | Evaluates the health of your peripheral nerves and your spinal cord. Test how your spinal cord/brain transmits information about body sensations through your peripheral nerves |
| Separate procedure | A procedure that is commonly part of another more complex procedure, but which may be performed independently or be otherwise unrelated to the procedure |
| Sentinel event | According to the JC, unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof. Serious injury specifically includes loss of limb or function. Signal the need for immediate investigation and response. |
| Sensitivity level | A security level associated with the content of the information |
| Semistructured question | A type of question that begins with structure question and follow with an unstructured question and follow with an unstructured question to clarify |
| Semicolon | A punctuation mark [;] placed after a procedure description within a CPT code set to avoid repeating common information |
| Semantics | The meaning of a word or term; sometimes refers to comparable meaning, usually achieved through a standard vocabulary |
| Semantic normal form (SNF) | The preferred term for clinical drugs in RxNorm |
| Semantic Network | The network that represents a consistent categorization of all concepts represented in the UMLS Metathesarus |
| Semantic interoperability | Mutual understanding of the meaning of data exchanged between information system |
| Semantic differential scale | A measure that records a group's perception of a product, organization, or program through bipolar adjectives on a seven-point continuum, resulting in a profile |
| Semantic Data Model (SDM) | A natural application modeling mechanism that can capture and express the structure of an application environment LOINC is an example of a semantic data model. |
| Semantic Clinical Drug (SCD) of RxNorm aka semantic clinical drug | Standardized names created in RxNorm for every clinical drug; consists of components and a dose form |
| Semantic clinical drug component (SCDC) | One of the two types of semantic normal forms created in RxNorm for every clinical drug, the SCDC consists of an active ingredient and strength |
| Self-reported health status | A method of measuring health status in which a person rates his or her own general health, for ex by using a five-category classification-excellent, very good, good, fair or poor |
| Self-pay | Type of fee-for-service reimbursement in which the patients or their guarantors pay a specific amount for each service received |
| Self-monitoring | The act of observing the reactions of others to one's behavior and making the necessary behavioral adjustments to improve the reactions of others in the future |
| Self-insured plan | Method of insurance in which the employer or other association itself administers the health insurance benefits for its employees or their dependents, thereby assuming the risks for the costs of healthcare for the group |
| Self-efficacy | Confidence in one's personal capabilities to do a job. The belief in one's capacity to organize and carry out a course of action to manage a situation. |
| Self-directed learning | An instructional method that allows students to control their learning and progress at their own pace. |
| Selective catheter placement | Catheter placement into any arterial or venous vessel other than the aorta, vena cava, or the original vessel that was punctured |
| Selection | The act or process of choosing |
| Security threat | A situation that has the potential to damage a healthcare organization's information system. |
| Security Standards | Statements that describe the processes and procedures meant to ensure that patient-identifiable health information remains confidential and protected from unauthorized disclosure, alternation, and destruction |
| Security Rule | The federal regulations created to implement the security requirements of the Health Insurance Portability and Accountability Act of 1996 |
| Security pyramid | A graphic representation of security measures in which each depends on the one below it |
| Security program | A plan outlining the policies and procedures created to protect healthcare information |
| Security officer or chief security officer | The Security Rule mandates an individual to be in charge of the security program for the covered entity. HIPAA calls this individual a security official; however this position is frequently called chief security officer (CSO) by the covered entities. Thi |
| Security management | The oversight of facilities equipment, and other resources, including human resources and technology, to reduce the possibility of harm to or theft of these assets of an organization. |
| Security breach | A violation of the policies or standards developed to ensure security. |
| Security audit process | A process put into place by a healthcare organization to monitor the effectiveness of its security program and to ensure compliance with it. |
| Security | Means to control access & protect information from accidental or intentional disclosure to unauthorized persons and from unauthorized alteration, destruction, or loss. The physical protection of facilities and equipment from theft, damage, or unauthorized |
| Securities & Exchange Commission (SCE) | The federal agency that regulates all public and some private transaction involving the ownership and debt of organization |
| Secure messaging system aka secure notification delivery system | A system that eliminates the security concerns that surround e-mail, but retains the benefits of proactive traceable, and personalized messaging |
| Second opinion | Opinion obtained from a second physician regarding the necessity for a treatment that has been recommended by the first physician. Cost containment measure to prevent unnecessary tests, treatments, medical devices, or surgical procedure |
| Secondary variable aka Confounding variable aka extraneous variable | In research an event or factor that is outside a study but occurs concurrently with the study |
| Secondary storage | The permanent storage of data and programs on disks or tapes |
| Secondary source | A summary of an original work, such as an encyclopedia |
| Secondary research | Processing data that has already been collected by another party |
| Secondary release of information | A type of information release in which the initial requester forwards confidential information to others without obtaining required patient authorization |
| Secondary insurer | The insurance carrier that pays benefits after the primary payer has determined and paid its obligation |
| Secondary diagnosis | A statement of those conditions coexisting during a hospital episode that affects the treatment received or the length of stay |
| Secondary data source | Data derived from the primary patient record, such as an index or database |
| Secondary care | A general term for healthcare services provided by a specialist at the request of the primary care physician. |
| Secondary analysis | A method of research involving analysis of the original work of another person or organization |
| Search engine | A software program used to search for data in databases (Ex structured query language) |
| Screen prototype | A sketch of the user interface of each screen that is anticipated in a project |
| Screening mammography | Breast imaging, usually done with two views bilaterally, to detect unsuspected cancer in an asymptomatic woman. |
| Scorecards aka dashboards | Reports of outcomes measures to help leaders know what they have accomplished |
| Scope of work | A term used in project management. A document that sets forth requirements for performance of work to achieve the project objectives. |
| Scope of command | The number and type of employees who report to a specific management position in a defined organizational structure. |
| Scope creep | A process in which the scope of a project grows while the project is in process, virtually guaranteeing that it will be over budget and behind schedule. |
| Scope | A term used in project management. A scope is detailed statement that outlines and describes all work necessary to complete a project. |
| Scientific management | A principle that states that the best management is a science based on laws and rules and that secures maximum prosperity for both employer and employee |
| Scientific inquiry | A process that comprises making predictions, collecting and analyzing evidence, testing alternative theories, and choosing the best theory. |
| Scheduling engine | A specific functionality in project management software that automates the assignment of task start and finish dates and, as a result, the expected project finish date |
| Scenarios | Stories describing the current and feasible future states of the business environment |
| Scatter plot aka scatter diagram, scattergram | A visual representation of data points on an interval or ratio level used to depict relationships between two variables |
| Scatter diagram aka scatter diagram | A graph that visually displays the linear relationships among factors |
| Scanning | The process by which a document is read into an optical imaging system |
| Scales of measurement | A reference standard for data collection and classification |
| Scale | Measure with progressive categories, such as size, amount, importance, rank, or agreement |
| Scalar Chain | A theory in the chain of command in which everyone is included and authority and responsibility flow downward from the top of the organization. |
| Scalable | The measure of a system to grow relative to various measures of size, speed, number of users, volume of data and so on |
| Satisficing | A decision-making process in which the decision maker accepts a solution to a problem that is satisfactory rather than optimal. |
| Satellite clinic | A primary care facility, owned and operated by a hospital or other organization, which is located in an area convenient to patients or close to a specific patient population |
| Sanctions | Penalties or other methods of enforcement used to provide incentives form compliance with laws or rules and regulations such as the HIPAA Privacy and Security Rules and related policies and procedures of the covered entity; sanctions should be uniform acr |
| Sample survey | A type of survey that collects data from representative members of a population |
| Sample size calculation | The qualitative and quantitative procedures to determine an appropriate sample size |
| Sample size | The number of subjects needed in a study to represent a population |
| Sample | A set of units selected for study that represents a population |
| Safety management | A system for providing a risk-free environment for patients, visitors, and employees |
| Safe practice | Behaviors undertaken to reduce or prevent adverse effects and medical errors |
| RXNORM | A clinical drug nomenclature developed by the Food and Drug Administration, the DVA, and HL7 to provide standard names for clinical drugs and administered dose forms |
| Relative weight (RW) | Assigned weight that reflects the relative resource consumption associated with a payment classification or group; higher payments are associated with higher relative weights |
| Relative value unit (RVU) | A number assigned to a procedure that describes its difficulty and expense in relationship to other procedures by assigning weights to such factors as personnel, time, and level of skill; |
| Relative value scale (RVS) | System designed to permit comparisons of the resources needed or appropriate prices for various units of service, taking into account labor, skill, supplies, equipment, space and other costs for each procedure or service; specifically refers to relative p |
| Rural area aka core-based statistical area (CBSA); metropolitan statistical area (MSA) | Geographic area outside an urban area and its constituent counties or count equivalents. Any area not designated as a metropolitan statistical area for the purposes of case-mix index sets and wage index adjustments to federal Medicare reimbursement rate |
| Run chart | A type of graph that shows data points collected over time and identifies emerging trends or patterns. |
| Rules engine | A computer program that applies sophisticated mathematical models to data that generate alerts and reminders to support healthcare decision making |
| Rules and regulations aka bylaws | Operating documents that describe the rules and regulations under which a healthcare organization operates |
| Rule induction aka association rule analysis | The process of extracting useful if/then rules from data based on statistical significance |
| Resource Utilization Group Version III (RUG-III) | A case-mix-adjusted classification system based on Minimum Data Set assessments and used by skilled nursing facilities |
| Rubric | A category; in ICPC, the two digits following the first character of an ICPC code and representing the second axis, component |
| Respiratory therapy (RT) | Services provided by a qualified professional for assessment, treatment, and monitoring of patients with deficiencies or abnormalities of pulmonary function |
| Relative risk (RR) | A ratio that compares the risk of disease between two groups |
| Row/record | A set of columns or a collection of related data items in a table |
| Router | A device that attaches multiple networks and routes packets between the networks using software |
| Review of systems (ROS) | A uniform system of performing an inventory of body systems through a series of questions seeking to identify signs and/or symptoms the patient may be experiencing or has experienced |
| Root operation | The third character of an ICD-10-PCS code that defines the objective of the procedure |
| Root concept | A single special concept that represents the root of the entire content in SNOMED CT |
| Root-cause analysis | A technique used in performance improvement initiatives to discover the underlying causes of a problem. Analysis of a sentinel event from all aspects (human, procedural, machinery, material) to identify how each contributed to the occurrence of the event |
| Risk of mortality (ROM) | The likelihood of an inpatient death for a patient |
| Roles and responsibilities | The definition of who does what on a project and the hierarchy for decision making |
| Role theory | Thinking that attempts to explain how people adopt specific roles, including leadership roles |
| Role playing | A training method in which participants are required to respond to specific problems they may actually encounter in their jobs. |
| Role-based access control (RBAC) | A control system in which access decisions are based on the roles of individual users as part of an organization. |
| Relational online analytical processing (ROLAP) | A data access methodology that provides users with various drill-down and business analysis capabilities similar to online analytical processing |
| Release of information (ROI) | The process of disclosing patient-identifiable information from the health record to another party |
| Return on investment (ROI) | The financial analysis of the extent of value a major purchase will provide |
| Return on equity (ROE) | A more comprehensive measurement of a profitability that takes into consideration the organization's net value |
| Registered nurse (RN) | A graduate nurse who has passed a national licensing examination |
| Regenstrief medical records system (RMRS) | One of the nation's first electronic medical record systems and the keystone of Regenstrief Institute activities |
| Risk management (RM) | A comprehensive program of activities intended to minimize the potential for injuries to occur in a facility and to anticipate and respond to ensuring liabilities for those injuries that do occur. The processes in place to identify, evaluate, and control |
| Record locator service (RLS) | A service that indicates where a given patient may have health information, using probability equations |
| Risk treatment | The application of risk control and risk financing techniques to determine how a risk should be treated, often aimed at preventing or reducing or reducing the chances and/or effects of a loss occurrence |
| Risk-transfer mechanism | A mechanism whereby risk is passed from a regulated insurer to a quasi-regulated, regulated, or nonregulated provider |
| Risk sharing agreement | An agreement in which a vendor assumes at least part of the responsibility, from a financial perspective, for a successful computer system implementation |
| Risk prevention | One component of a successful risk management program |
| Risk pool | Distribution of risk among a larger group of persons (insured). This group of persons have similar risks of loss |
| Risk financing | Methods used to pay for the costs associated with claims and other expenses; most commonly, liability insurance |
| Risk exposure or identification | A systematic means of identifying potential losses, which requires an understanding of the facility's business, legal, organizational, and clinical component |
| Risk evaluation | The final step in the risk management process, which involves evaluating each piece of the process in order to determine whether objectives are being met. |
| Risk corridors | Established by the Medicare Prescription Drug Improvement, and Modernization Act of 2003 for prescription drug plans and Medicare Advantage drug plans to help keep payments in line with actual costs while giving plans an incentive to control these costs. |
| Risk analysis aka risk assessment | The process of identify possible security threats to the organization's data and identifying which risks should be proactively addressed and which risks are lower in priority |
| Risk adjustment | Any method of comparing the severity of illness of one group of patients with that of another group of patients. Case-mix adjustment, severity of illness adjustment |
| Risk | The probability of incurring injury or loss. The probable amount of loss foreseen by an insurer in issuing a contract. A formal insurance term denoting liability to compensate individuals for injuries sustained in a healthcare facility |
| Rip-and-replace | An information technology acquisition strategy in which older technology is replaced with new technology |
| Radioimmunoprecipitation assay (RIPA) | A confirmatory blood test that is used to detect HIV infection. It is used when HIV antibody levels are very low or difficult to detect |
| Right-to-work laws | Federal legislation dealing with labor rights (ex Workers' compensation, child labor, and minimum wage law) |
| Rider | Document added to a healthcare insurance policy that provides details about coverage or lack of coverage for special situations that are not usually included in standard policies; may function as an exclusion or limitation |
| Rehabilitation impairment category (RIC) | Clusters of impairment group codes (IGCs) that represent similar impairments and diagnoses. The larger umbrella division within the inpatient rehabilitation facility prospective payment system (IRF PPS). Due to this the case-mix group (CMGs) are determine |
| Registered health information technician (RHIT) | A type of certification granted after completion of an AHIMA-accredited two-year program in health information management and a credentialing examination |
| Regional health information organization (RHIO) | A heath information organization that brings together-healthcare stakeholders within a defined geographic area and governs health information exchange among them for the purpose of improving health and care in the community |
| Regional health information network (RHIN) | System that links various healthcare information systems in a region together so that patients, healthcare institutions, and other entities can share clinical information |
| Registered health information administrator (RHIA) | A type of certification granted after completion of an AHIMA-accredited four-year program in health information management and a credentialing examination |
| Regional home health intermediaries (RHHI) | Private companies that contract with Medicare to pay home health bills and check on the quality of home healthcare |
| Request for proposal (RFP) aka request for application | A type of business correspondence asking for very specific product and contract information that is often sent to a narrow list of vendors that have been preselected after a review of requests for information during the design phase of the systems develop |
| Radio frequency identification (RFID) | An automatic recognition technology that uses a device attached to an object to transmit data to a receiver and does not require direct contact |
| Request for information (RFI) | A written communication often sent to a comprehensive list of vendors during the design phase of the systems development life cycle to ask for general product information |
| Reasons for encounter (RFE) | In the international classification of primary care (ICPC) system, the subjective experience by the patient of the problem |
| Rewarding stage | In performance management, the fifth of five stages during which individual employees are rewarded for exceptional achievement |
| Revocation | The act of withdrawing an authorization or permission that was previously granted as in the case of consents or authorizations to disclose information or requesting restrictions. |
| Revision | Correcting to the extent possible, a malfunctioning or displaced device. Can include correcting a malfunctioning device by taking out and/or putting in part but not all of the device. Correction or alteration of the health record. |
| Reverse mentoring | The opposite of the usual coaching process where the younger goes to the older instructor |
| Revenues | The charges generated from providing healthcare services, earned and measurable income |
| Revenue cycle management | The supervision of all administrative and clinical functions that contribute to the capture, management, and collection of patient service revenue, with the goals of accelerated cash flow and lowered accounts receivable. |
| Revenue cycle | The process of how patient financial & health information moves into through and out of the healthcare facility, culminating with the facility receiving reimbursement for services provided. The regularly repeating set of events that produces revenue |
| Revenue code | A 3 or 4 digit number in the chargemaster that totals all items and their charges for printing on the form used for Medicare billing. |
| Revenue | The charges generated from providing healthcare services earned and measurable income. |
| Revenge effects | Unintended and typically negative consequences of a change in technology. |
| Return on assets (ROA) | The return on a company's investment, or earnings, after taxes divided by total assets. |
| Return | The increase in value of an investment |
| Retrospective utilization review | A review of records some time after the patient's discharge or date of service to determine any of several issues, including the quality or appropriateness of the care provided. |
| Retrospective study | A type of research conducted by reviewing records from the past (ex birth & death certificates, health record) or by obtaining information about past events through surveys or interviews |
| Retrospective review | The part of the utilization review process that concentrates on a review of clinical information following patient discharge |
| Retrospective payment system aka retrospective payment method | Type of fee-for-service reimbursement in which providers receive recompense after health services have been rendered |
| Retrospective coding | A type of coding that takes place after the patient has been discharged and the entire health record has been routed to the health information management department |
| Retrospective | A type of time frame that looks back in time |
| Retrograde | Moving backward, against the normal flow |
| Retrievability | Efficiently finding relevant information |
| Retraction | The act of correcting information that was inaccurate, invalid, or made in error preventing its display or finding the entry or documentation |
| Retinal detachment | The separation of two layers of the retina from each other which usually occurs when the vitreous adheres to the retina (the sensitive layer of the eye) and 'pull' resulting in retinal holds that tear that may lead to retinal detachment |
| Retention schedules | A time line for various records retention based on factors such as federal and state law, statutes of limitations, age of patient, competency of patient, accreditation standards, AHIMA recommendations, and operational needs |
| Retention policy | A policy that establishes how long the healthcare facility should keep health records, the medium in which the information will be kept, & where the records will be located and retrieved. Types of information retained may vary by state & accrediting body |
| Retention | Mechanisms for storing records, providing for timely retrieval, and establishing the length of times that various types of records will be retained by the healthcare organization. The ability to keep valuable employees from seeking employment elsewhere. |
| Retaliation and waiver | Rights protected under the Privacy Rule, to ensure the integrity of individuals' right to complain about alleged Privacy Rule violations, covered entities are expressly prohibited from retaliating against anyone who exercise his righst under the Privacy R |
| Retained earnings | Undistributed profits from a for-profit organization that stay in the business |
| Results retrieval | A lookup system that enables a user to access several different types of data from different source systems through a single application screen |
| Results management aka results management systems | Results retrieval technology that permits viewing of data by type and manipulation of several different types of data |
| Resubmittal aka rebill | The process of sending a corrected, or now complete, claim to an insurance company for reconsideration of the original payment or denial |
| Restriction | Partially closing an orifice or the lumen of a tubular body part. Coded when the objective of the procedure is to narrow the diameter of a tubular body part or orifice ICD-10-PCS |
| Restraints and seclusion | Ways of managing behavior; the right of patients to be free from non-medically necessary restraints and seclusion is protected under the Medicare Conditions of Participation |
| Restorative nursing care | Care that incorporates resident-specific programs that restore and preserve function to assist the resident in maximizing functional independence and achieving a satisfactory quality of life. |
| Restitution | The act of returning something to its rightful owner, of making good or giving something equivalent for any loss damage or injury |
| Responsibility center | A department as a whole, headed by an individual who is responsible for operation. |
| Responsibility | The accountability required as part of a job, such as supervising work performed by others or managing assets or funds. |
| Respite care | A type of short-term care provided during the day or overnight to individuals in the home or institution to temporarily relieve the family home caregiver. |
| Respect for Persons | The principle that all people are presumed to be free and responsible and should be treated accordingly |
| Resources | The labor, equipment, or materials needed to complete a project |
| Resource intensity | The relative volume and types of diagnostic, therapeutic, and bed services used in the management of a particular illness. |
| Resource-based relative value scale (RBRVS) | A Medicare reimbursement system implemented in 1992, to compensate physicians according to a fee schedule predicated on weights assigned on the basis of the resources required to provide the services. |
| Resident's right to access | A term encompassing the mechanisms in place to allow residents to review their own health information. |
| Resident record | A term frequently used in long-term care in lieu of health record |
| Residential care | Services including board and lodging, provided in a protective environment but with minimal supervision to residents who are not in an acute phrase of illness and would be capable of self-preservation during an emergency |
| Residential arrangement | The situation in which an individual lives on a regular basis-owns a home or apartment, resides in a facility where health, disability, or aging-related services or supervision are available; resides in another residential setting where no services are pr |
| Resident classification system | A system for classifying skilled nursing facility residents into mutually exclusive groups based on clinical, functional and resource-based criteria |
| Resident care facility for the elderly (RCFE) | A residential facility that provides room, board, housekeeping, supervision, and personal care assistance for persons who are unable to live by themselves but who do not need 24-hour nursing care. |
| Resident care facility | A facility that provides accommodations, supervision, and personal care services for those who are dependent on services of others due to age or physical or mental impairment. |
| Resident Assessment Validation and Entry (RAVEN) | A type of data-entry software developed by the Centers for Medicare and Medicaid Services for long-term care facilities and used to collect Minimum Data Set Assessments and to transmit data to state databases |
| Resident assessment protocol (RAP) | A summary of a long-term care resident's medical condition and care requirements |
| Resident assessment instrument (RAI) aka MDS | A uniform assessment instrument developed by the Center for Medicare and Medicaid Services to standardize the collection of skilled nursing facility patient data; includes the MDS 2.0, triggers, and resident assessment protocols |
| Resident | A common synonym for patient, especially in long-term care. A graduate physician in post-graduate hospital clinical training |
| Residency program | An accredited program whereby a hospital sponsors graduate medical education for physicians in training and in the case of residencies in the clinical dividions of medicine, surgery, and other special fields, advanced training in preparation for the prac |
| Residence | A patient's full address and zip code |
| Reserves | Unused profits from a not-for-profit organization that stay in the business |
| Resection | Cutting out or off, without replacement, all of a body part. Includes al of the body part or any subdivision of a body part that has its own body part value in ICD-10-PCS |
| Research methodology | A set of procedures or strategies used by researchers to collect, analyze, and present data |
| Research method | The particular strategy used by a researcher to collect, analyze, and present data |
| Research data | Data used for the purpose of answering a proposed question or testing a hypothesis |
| Research | An inquiry process aimed at discovering new information about a subject or revising old information. Investigation or experimentation aimed at the discovery and interpretation of facts, revision of accepted theories or laws in the light of new facts, or p |
| Requisition | A request from an authorized health record user to gain access to a medical record |
| Required standards | The implementation specifications of the HIPAA Security Rule that are designated 'require' rather than 'addressable' required standards must be present for the covered entity to be in compliance |
| Request restrictions | Under the Privacy Rule, the right of an individual to request that a covered entity limit the uses and disclosures of PHI to carry out treatment, payment, or healthcare operations. |
| Request for production | A discovery device used to compel another party to produce documents and other items or evidence important to a lawsuit. |
| Repudiation | A situation in which a user or system denies having performed some action, such as modifying information |
| Repository | A data structure where data are stored for subsequent use by multiple, disparate system |
| Reposition | Moving all or a portion of a body part to its normal location or the other suitable location in (ICD-10-PCS) |
| Report generation | The process of analyzing, organizing, and presenting recorded patient information for authentication and inclusion in the patient's healthcare record, the formatting and/or structuring of captured information. |
| Report card | A method used by managed care organizations (and other healthcare sectors) to report cost and quality of care provided |
| Reportable adverse event | An unintended act, either of omission or commission, or an act that does not achieve its intended outcome. |
| Replacement | Putting in or on biological or synthetic material that physically takes the place and/or function of all or a portion of a body part in ICD-10-PCS |
| Repair | Restoring to the extent possible, a body part to its normal anatomical structure and function. It also functions as the not elsewhere classified (NEC) root operation and is to be used when the procedure performed does not meet the definition of one of the |
| Removal | Taking out or off a device from a body part in ICD-10-PCS |
| Remote patient monitoring device | A device that enables a healthcare provider to monitor and treat a patient from a remote location |
| Remittance advice (RA) | An explanation of payment (Ex claim denials) made by third-party payers. |
| Reminder | A prompt based on a set of rules that displays on the computer workstation, similar to a recommendation |
| Regenstrief LONIC Mapping Assistant (RELMA) | |
| Reliability | A measure of consistency of data items based on their reproducibility and an estimation of their error of measurement |
| Relevance | How applicable information is to some matter |
| Release of disclosure | The processes that make health record information available to legitimate users |
| Release | Freeing a body part from an abnormal physical constraint by cutting or by use of force. Coded to the body part being freed in ICD-10-PCS |
| Relative value study (RVS) | A guide that shows the relationship among the time resources, competency, experience, severity, and other factors necessary to perform procedures. |
| Relative Frequency | The percentage of times that a character appears in a data set |
| Relationship | A type of connection between two terms |
| Relational online analytical processing (ROLAP) | A data access methodology that provides users with various drill-down and business analysis capabilities similar to online analytical processing |
| Relational database management system (RDBMS) | A database management system in which data are organized and managed as a collection of tables |
| Relational database | A type of database that stores data in predefined tables made up of rows and columns |
| Rejection | The process of having a submitted bill not accepted by the payer, although corrections can be made and the claim resubmitted |
| Reinforcement | The process of increasing the probability of a desired response through reward |
| Reimbursement | Compensation or repayment for healthcare services |
| Rehabilitation Services | Health services provided to assist patients in achieving and maintaining their optimal level of function, self-care, and independence after some type of disability. |
| Rehabilitation facility | Facility specializing in restorative processes and therapies that develop and maintain self-sufficient functioning consistent with individuals' capabilities. Restore function after an illness or injury. |
| Rehabilitation Act | Federal legislation passed in 1973 to protect handicapped employees against discrimination |
| Regulation | A rule established by an administrative agency of government. The difference between a statute and a regulation participating in the related program. Administrative agencies are responsible for implementing and managing the program instituted by state and |
| Regression analysis | Statistical technique that uses an independent variable to predict the value of a dependent variable. In the inpatient psychiatric facility prospective payment system (IPF PPS), patient demographics and length of stay (independent variables) were used to |
| Registry | A collection of care information related to a specific disease, condition, or procedure that makes health record information available for analysis and comparison. |
| Registration data of the admission, discharge, transfer (R-ADT) | A type of administrative information system that stores demographic information and performs functionality related to registration, admission, discharge, ad transfer of patients within the organization. |
| Registration | The act of enrolling |
| Refreezing | Lewin's last stage of change in which the new behaviors are reinforced to become as stable and institutionalized as the previous status quo behaviors. |
| Reflective learning cycle | Uses awareness to formulate an interpretation of what has been observed, considers what difference can be made by applying what has been learned, and executes the efforts toward change through deliberate action. A cycle of reflection, interpretation, appl |
| Refined case-based payment method | Case-based payment method enhanced to include patients from all age groups or from regions of the world with varying mixes of disease and differing patterns of healthcare delivery |
| Referred outpatient | An outpatient who is provided special diagnostic or therapeutic services by a hospital on a ambulatory basis but whose medical care remains the responsibility of the referring physician |
| Referral | A request by a provider for a patient under the provider care to be evaluated and/or treated by another provider |
| Reference terminology | A set of concepts and relationships that provide a common consultation point for the comparison and aggregation of data about the entire healthcare process, recorded by multiple individuals, systems, or institutions |
| Reference data | Information that interacts with the care of the individual or with the healthcare delivery system, such as a formulary, protocol, care plan, clinical alert, or reminder |
| Reference check | Contact made with an individual that a prospective employee has listed to provide a favorable account of his or her work performance or personal attributes |
| Refereed journal aka Peer-reviewed journal | A type of professional or scientific journal for which content experts evaluate articles prior to publication |
| Reengineering | Fundamental rethinking and radical redesign of business processes to achieve significant performance improvements |
| Redundant arrays of independent (or inexpensive) disks (RAID) | A method of ensuring data security. |
| Redundancy | As data is entered and processed by one server, data is simultaneously being entered and processed by a second server. The concept of building a backup computer system that is an exact version of the primary system and that can replace it in the event of |
| Redisclosure | The release, transfer, provision of access to, or divulging in any other manner of patient health information that was generated by an external source to others outside of the organization and its workforce members |
| Red flags | Suspicious documents, information, or behaviors that indicate the possibility of identity theft. |
| Red flag Rules | A set of FTC regulations that require certain entities to develop and implement identity theft prevention programs |
| Recurrence | A return of symptoms as part of the natural progress of a disease |
| Recruitment | The process of finding, soliciting, and attracting employees. |
| Recovery room record aka recovery room report | A type of health record documentation used by nurses to document the patient's reaction to anesthesia and condition after surgery. |
| Recovery audit contractor (RAC) | A governmental program whose goal is to identify improper payments made on claims of healthcare services provided to Medicare beneficiaries. Improper payment may be overpayment or underpayment |
| Recovery Act aka American Recovery and Reinvestment Act of 2009 aka stimulus | Enacted by the 11th US Congress in 2/09; signed into law by Obama 2/17/09; unprecedented effort to jumpstart the economy, create/save millions of jobs, & put down payment on addressing long-neglected challenges; an extraordinary response to crisis unlike |
| Records retention policy | A policy that specifies the length of time that health records are kept as required by law and operational needs. |
| Records purging policy | A policy that is used in conjunction with the off-site storage policy and retention policy. |
| Records disaster recovery policy | A policy that establishes how records should be handled in a disaster such as fire or flood |
| Record reconciliation | The process of assuring that all the records of discharged patients have been received by the HIM department for processing |
| Record processing | The processes that encompass the creation, maintenance, and updating of each patient's medical record |
| Record of Care, Treatment, and Services | A chapter in the Joint Commission accreditation manual that provides standards for managing health information specifically addressing the clinical record itself. |
| Record custodian | The person who has been designated responsible for the care, custody, and control of the health record for such persons or institutions that prepare and maintain records of healthcare. They are authorized to certify records and supervise all inspections, |
| Record completion | The process whereby healthcare professionals are able to access, complete, and/or authenticate a specific patient's medical information |
| Receivables aka assets | Amounts of money coming into the organization |
| Recapitulation (Recap) | A concise summary of data |
| Recalibration | The adjustment of all ambulatory payment classification weights to reflect changes in relative resource consumption |
| Rebill | The act of resubmitting a corrected bill to the payer after it has been rejected. |
| Rebasing | The redetermination of the ambulatory payment classification weights to reflect changes in relative resource consumption |
| Reattachment | Putting back in or on all or a portion of a separated body part to its normal location or other suitable location. During this procedure the vascular circulation and nervous pathways may or may not be reestablished |
| Reasonable care | The degree of care that a reasonably prudent person would exercise in the same or similar circumstances. |
| Reasonable and customary charges (R&C) aka usual, customary, and reasonable | The amounts charged by healthcare providers consistent with charges from similar providers for identical or similar services in a given locale |
| Real audio data aka sound data | The storing, manipulating, and displaying of sound in a computer-readable format |
| Reagent | Any substance added to a solution of another substance to participate in a chemical reaction. |
| Readiness Assessment | An evaluation of a healthcare organization's infrastructure to identify and capture information on what must be addressed and where to apply resources in preparation for change such as an EHR implementation or ICD-10 transition |
| Read Codes aka Clinical Terms Version 3 | The former name of the UK CTV-3 codes; named for James Read, the physician who originally devised the system to organize computer-based patient data in his primary care practice |
| Randomized clinical trail (RCT) | A special type of clinical trial in which the researchers follow strict rules to randomly assign patients to groups. |
| Ratio scale | Continuous data having both equal intervals and an absolute zero point |
| Ratio-level data aka ratio data aka interval-level data | Data with a defined unit of measure, a real zero point, and with equal intervals between successive values |
| Ratio data | Data that may be displayed by units of equal size and placed on a scale starting with zero and thus can be manipulated mathematically (ex 0, 5, 10, 15, 20) |
| Ratio analysis | Mathematical compulations that compare elements of an organization's financial statements to past and future performance. |
| Ratio | A calculation found by dividing one quantity by another. A general term that can include a number of specific measures such as proportion, percentage, and rate |
| Rating stage | In performance management, the fourth of five steps during which specific performance criteria are evaluated. |
| Rate of return method | A method used to justify a proposed capital expenditure in which the organization tries to find out what rate of return it would get if it invests in a particular project. |
| Rate | A measure used to compare an event over time; a comparison of the number of times an event did happen (numerator) with the number of times an event could have happened (denominator) |
| Raster image | A digital image or digital data made up of pixels in a horizontal and vertical grid or a matrix instead of lines plotted between a series of points |
| Ranked data | A type of ordinal data where the group of observations is first arranged from highest to lowest according to magnitude and then assigned numbers that correspond to each observation's place in the sequence. |
| Range | A measure of variability between the smallest and largest observations in a frequency distribution |
| Random, Sampling | An unbiased selection of subjects that includes methods such as simple random sampling, stratified random sampling, systematic sampling, and cluster sampling. |
| Randomization | The assignment of subjects to experimental or control groups based on chance |
| Radiology information system (RIS) | A system that collects, stores, and provides information on radiological tests such as ultrasound, magnetic resonance imaging, and positron emission tomography. The It supports other radiological procedures performed in radiology such as ultrasound-guided |
| Radioimmunoassay | A procedure that combines the use of radioactive chemicals and antibodies to detect hormones and drugs in a patient's blood. |
| Radioactive source | Radioactive elements packaged in a small configuration used for permanent implantation into tumors |
| Radioactive ribbon | A small plastic tube (ribbon) that has radioactive sources spaced at regular lengths along it. Ribbon refers to temporary interstitial placement |
| Quotient | The number resulting from the division of one number by another |
| Quota sampling | A sampling technique where the population is first segmented into mutually exclusive subgroups, just as in stratified sampling, and then judgment is used to select the subjects or units from each segment based on a specified proportion. |
| Qui tam | The 'whistleblower' provisions of the False Claims Act which provides that private persons, known as a relators, may enforce the Act by filing a complaint, under seal, alleging fraud committed against the government. |
| Quintile | Portion of a frequency distribution containing one-fifth of the total cases |
| Queuing theory | An operations management technique for examining customer flow and designing ideal wait or scheduling times. |
| Questionnaire | A type of survey in which the members of the population are questioned through the use of electronic or paper forms. |
| Questionable covered procedure | A procedure that may or may not be covered, depending on the patient's diagnosis and other factors |
| Quasi experimental design aka causal-comparative research | A research design that resembles experimental research but lacks random assignment to a group and manipulation of treatment |
| Quartile | The fourth equal part of a distribution |
| Quantitative research aka quantitative approach aka positivism | A philosophy of research that assumes that there is a single truth across time and place and that researchers are able to adopt a neutral, unbiased stance and establish causation |
| Quantitative audit aka biling audit | An audit that compares a report of services billed for a specific client and within a specific time frame against the health record documentation |
| Quantitative analysis | A review of the health record to determine its completeness and accuracy |
| Quality review organization | A quality improvement organization or an accreditation organization |
| Quality measures aka performance measure | A quantitative tool used to assess the clinical, financial, an utilization aspects of a healthcare provider's outcomes or processes. |
| Quality management | Evaluation of the quality of healthcare services and delivery using standards and guidelines developed by various entities, including the government and independent accreditation organizations. |
| Quality indicator (QI) | A standard against which actual care may be measured to identify a level of performance for that standard |
| Quality improvement process | An approach undertaken to improve healthcare delivery that involves two principal steps-problem identification and process design. |
| Quality improvement organization (QIO) | An organization that performs medical peer review of Medicare and Medicaind claims, including review of validity of hospital dx & procedure coding information; completeness, adequacy, & quality of care & appropriateness of prospective payments for outlier |
| Quality improvement (QI) | A set of activities that measures the quality of a service or product through systems or process evaluation and then implements revised processes that result in better healthcare outcomes for patients, based on standards of care |
| Quality gap | The difference between approved standards, criteria, or expectations in any type of process and actual results |
| Quality assurance (QA) | A set of activities designed to measure the quality of a service, product, or process with remedial action, as needed, to maintain a desired standard |
| Quality | The degree or grade of excellence of goods or services including, in healthcare, meeting expectations for outcomes |
| Qualitative standards | Service standards in the context of setting expectations for how well or how soon or a service will be performed |
| Qualitative research | A philosophy of research that assumes that multiple contextual truths exist and bias is always present. |
| Qualitative approach aka naturalism | A philosophy of research that assumes that multiple contextual truths exist and bias is always present |
| Qualitative analysis | A review of the health record to ensure that standards are met and to determine the adequacy of entries documenting the quality of care |
| Qualifying individuals (QI) | Medicare beneficiaries whose income are at least 120 percent, but less than 175 percent, of the federal poverty level. |
| Qualifying circumstances | Unusual situations such as extreme age, total body hypothermia, controlled hypotension, and emergency situations that complicate the provision of anesthesia. |
| Qualified Medicare beneficiaries (QMB) | Medicare beneficiaries who have resources at or below twice the standard allowed under the SSI program an incomes at or below 100% the federal poverty level |
| Qualified electronic health record | An EHR on an individual that includes pt demographic & clinical health information & has the capacity to provide clinical decision support; to support physician order entry; to capture and query information relevant to healthcare quality; and to exchange |
| Qualified disabled and working individuals (QDWIs) | Medicare beneficiaries who are eligible for assistance, including disabled and working people who previously qualified for Medicare because of disability but lost entitlement because of their return to work despite the disability |
| QI toolbox techniques | Tools that facilitate the collection, display, and analysis of data and information and that help team members stay focused, including cause-and-effect diagrams, graphic presentations, and others |
| PWW aka Group practice without walls | A type of managed care contract that allows physicians to maintain their own offices and share administrative services; Also called clinic without walls (CWW) |
| Push technology | A types of active computer technology that send information directly to the end user as the information becomes available. |
| Purposive sampling | A strategy of qualitative research in which researchers use their expertise to select representative units and unrepresentative units to capture a wide array of perspective. |
| Purged records | Patient health records that have been removed from the active file area |
| Purchase order | A paper document or electronic screen on which all details of an intended purchase are reported, including authorization. |
| Pull list | A list of request for records to be pulled for review during the audit process. |
| Pull-down menu | The design of a data-entry screen of a computer in which categories of functions or structured data elements may be accessed through that category element in a list format. |
| Puerperal | The period immediately following childbirth |
| Public law 104-191 | The alternate name for HIPAA passed in 1996 |
| Public law | A type of legislation that involves the government and its relations with individuals and business organizations |
| Public key infrastructure (PKI) | A system of digital certificates and other registration authorities that verify and authenticate the validity of each party involved in a secure transaction. |
| Public key | In cryptography, an asymmetric algorithm made publicly available to unlock a coded message |
| Public health services (PHS) | Services concerned primarily with the health of entire communities and population groups |
| Public Health Informatics Institute (PHII) | A cooperative of public health services, health information systems, and informatics experts established to develop health information systems for public and population health purposes. |
| Public health | An area of healthcare that deals with the health of populations in geopolitical areas, such as states and counties. |
| Public Company Accounting Oversight Board (PCAOB) | A not-for-profit organization that oversees the work of auditors of public companies |
| Public Assistance aka welfare | A monetary subsidy provided to financially needy individuals |
| P/T committee aka | pharmacy & therapeutic committee |
| PTCA | Percutaneous transluminal coronary angioplasty |
| PT aka physical therapy | The field of study that focuses on physical functioning of the resident on a physician-prescribed basis |
| Psychotherapy notes | Notes recorded in any medium by a mental health professional to document or analyze the contents of conversations between therapists and clients during private or group counseling sessions. |
| Psychiatry | The study, treatment, and prevention of mental disorders |
| Psychiatric hospital | A hospital that provides diagnostic and treatment services to patients with mental or behavioral disorders. |
| PSRO aka Professional standards review organization | An organization responsible for determining whether the care and services provided to hospital inpatients were medically necessary and met professional standards in the context of eligibility for reimbursement under the Medicare and Medicaid programs |
| PSO aka patient safety organization | Organizations that share the goal of improving the quality and safety of healthcare delivery; organizations eligible to become PSOs include public or private entities, profit or not-for-profit entities, provider entities such as hospital chains, and other |
| PSO aka provider sponsored organization | Type of point-of-service plan in which the physicians that practice in a regional or community hospital organize the plan. |
| PSI payment status indicator | An alphabetic code assigned to CPT/HCPCS codes to indicate whether a service or procedure is to be reimbursed under the Medicare outpatient prospective payment system |
| Patient Self-determination act (PSDA) | The federal legislation that requires healthcare facilities to provide written information on the patient's right to issue advance directives and to accept or refuse medical treatment. |
| Provider network organization | An organization that performs prospective, concurrent, and retrospective reviews of healthcare services provided to its enrollees |
| Provider-based status | The relationship between a main provider and a provider based entity or a department of a provider that complies with the provisions of the final rule on ambulatory payment classifications |
| Provider-based entity | A provider of healthcare services, a rural health clinic, or a federally qualified health clinic, as defined in section 405-2401 of the Code of Federal Regulations, that is either created or acquired by a main provider for the purpose of furnishing health |
| Provider | Physician, clinic, hospital, nursing home, or other healthcare entity (second party) that delivers healthcare services |
| Protocol | In healthcare, a detailed plan of care for a specific medical condition based on investigative studies; in medical research, a rule or procedure to be followed in a clinical trial; in a computer network, a rule or procedure used to address and ensure deli |
| Protective order | Any court order or decree whose purpose is to protect a person from personal harassment or service of process or discovery. |
| Protective health information (PHI) | Individually identifiable health information, transmitted electronically or maintained in any other form, that is created or received by a healthcare provider or any other entity subject to HIPAA requirement |
| Prosthetics and orthotics (P/O) | A collective term that refers to the artificial extremities augmentation devices, and mechanical appliances used in orthopedic care. |
| Prospective utilization review | A review of a patient's health records before admission to determine the necessity of admission to an acute care facility and to determine or satisfy benefit coverage requirements. |
| Prospective study | A study designed to observe outcomes or events that occur after the identification of a group of subjects to be studied |
| Prospective reimbursement aka prospective payment system | A type of reimbursement system that is based on preset payment levels rather than actual charges billed after the service has been provided; specifically, one of several Medicare reimbursement systems based on predetermined payment rates or periods and li |
| Prospective payment system (PPS) | A type of reimbursement system that is based on preset payment levels rather than actual charges billed after the service has been provided; specifically, one of several Medicare reimbursement systems based on predetermined payment rates or periods and li |
| Prospective payment method | Type of episode-of-care reimbursement in which the third-party payer establishes the payment rates for healthcare services in advance for specific time period |
| Prospective payment | A method of determining reimbursement based on predetermined factors, not individual services |
| Prosecutor | An attorney who prosecutes a defendant accused of a crime on behalf of a local, state, or federal government |
| Proportionate mortality ratio (PMR) | The total number of deaths due to a specific cause during a given time period divided by the total number of deaths due to all causes |
| Proportion | The relation of one part to another or to the whole with respect to magnitude, quantity, or degree |
| Property, plant, & equipment (PPE) aka capital assets | Physical assets with an estimated useful life of more than one year |
| Promotion | the act of being raised in position or rank |
| Project team | A collection of individuals assigned to work on a project |
| Project scope | The intention of a project. The range of a project' activities or influence |
| Project schedule | The portion of the project plan that deals specifically with task start and finish dates |
| Project plan | A plan consisting of a list of the tasks to be performed in a project, a defined order in which they will occur, task start & finish dates, and the resource effort needed to complete each task. |
| Project office | A support function for project management best practices |
| Project network | The relationship between tasks in a project that determines the overall finish date |
| Project management software | A type of application software that provides the tools to track a project |
| Project management life cycle | The period in which the processes involved in carrying out a project are completed, including project definition, project planning and organization, project tracking and analysis, project revisions, change control, and communication |
| Project management | A formal set of principles and procedures that help control the activities associated with implementing a usually large undertaking to achieve a specific goal, such as an information system project. |
| Project deliverables | The tangible end results of a project |
| Project definition | First step in the project management life cycle that sets expectations for the what, when, and how of a project the organization wants to undertake. |
| Project components | Related parameters of scope, resources, and scheduling with regard to a project. |
| Project charter aka statement of work (SOW) | A document that defines the scope and goals of a specific project |
| Prohibited abbreviations | Acronyms, abbreviations, and symbols that cannot be used in health records because they are prone to misinterpretation. |
| Progressive discipline | A four-step process for shaping employee behavior to conform to the requirements of the employee's job position that begins with a verbal caution and progresses to written, reprimand, suspension, and dismissal upon subsequent offenses. |
| Progress notes | The documentation of a patient's care, treatment, and therapeutic response, which is entered into the health record by each of the clinical professionals involved in a patient's care, including nurses, physician, therapists, and social workers. |
| Programs of All-inclusive care for the Elderly (PACE) | A state option legislated by the Balanced Budget Act of 1997 that provides an alternative to institutional care for individuals 55 years old or older who require the level of care provided by nursing facilities. |
| Programming language | A set of words and symbols that allows programmers to tell the computer what operations to follow |
| Programmers | Individuals primarily responsible for writing program codes and developing applications, typically performing the function of systems development and working closely with system analysts |
| Programmed decision | An automated decision made by people or computers based on a situation being so stable and recurrent that decision rules can be applied to it. |
| Program officer | The person who leads a specific request for applications (RFA) or request for proposals (RFP) and addresses any questions the investigators may have while developing a proposal |
| Program for Evaluation Payment Patterns Electronic Report (PEPPER) | A benchmarking database maintained by the Texas Medical Foundation that supplies individual QIOs with hospital data to determine state benchmarks and monitor hospital compliance |
| Program evaluation and review technique (PERT) chart | A project management tool that diagrams a project's time lines and tasks as well as their interdependencies |
| Project budget aka milestone budget aka program budget | A type of budget without a fixed 12-month calendar in which cost is determined and budget allocation is established for the next period as events are completed |
| Prognosis | The probable outcome of an illness, including the likelihood of improvement of deterioration in the severity of the illness, the likelihood for recurrence, and the patient's probable life expectancy. |
| Pro forma | An estimate |
| Profit and loss statement aka statement of revenue and expenses | A financial statement showing how much the organization makes or loses during a given reporting period |
| Profitability index | An index used to prioritize investment opportunities, where the present value of the cash inflows is divided by the present value of the cash outflows for each investment and results are compared. |
| Profit aka net income | The difference between revenue and expenses used to build reserves for contingencies and long-term capital improvements |
| Profiling | A measurement of the quality, utilization, and cost of medical resources provided by physicians that is made by employers, third-party payers, government entities, and other purchasers of healthcare. A technique used to compare the activities of one or mo |
| Professional component (PC) | The portion of a healthcare procedure performed by a physician. A term generally used in reference to the elements of radiological procedures performed by a physician |
| Professional certification organization | Private societies and membership organizations that establish professional qualification requirements and clinical practice standards for specific areas of medicine, nursing and allied health professions |
| Productivity software | A type of computer software used for word-processing spreadsheet, and database management applications. |
| Productivity indicators | A set of measures designed to routinely monitor the output and quality of products and/or services provided by an individual, an organization, or one of its constituent parts; used to help determine status of a productivity bonus. |
| Productivity bonus | A monetary incentive used to encourage employee to improve their output |
| Productivity | A unit of performance defined by management in quantitative standards |
| Product trade name | Name (aka catalog name) assigned or supplied by the labelers (firms) as required under Food drug Cosmetic at |
| Product code | The part of the National Drug Code that identifies a specific strength, dosage form, and formulation for a particular drug. |
| Process redesign | The steps in which focused data are collected and analyzed, the process is changed to incorporate the knowledge gained from the data collected, the new process is implemented, and the staff is educated about the new process |
| Process measures | Measures that focus on a process that leads to a certain outcome, meaning that a scientific basis exists for believing that the process, when executed well, will increase the probability of achieving a desired outcome. |
| Process indicators | Specific measures that enable the assessment of the steps taken in rendering a service |
| Process improvement team | An interdepartmental task force formed to redesign or change and improve shared processes and procedures |
| Process improvement | A series of actions taken to identify, analyze, and improve existing processes. |
| Process and workflow modeling | The process of creating a representation of the actions and information required to perform a function, including decomposition diagrams, dependency diagrams, and data flow diagrams |
| Process | A systematic series of actions taken to create a product or service |
| Procedures and services (outpatient) | All medical procedures and services of any type that are performed pertinent to the patient's reasons for the encounter, all therapeutic services performed at the time of the encounter, & all preventive services & procedures performed at the time of the e |
| Procedure | A document that describes the steps involved in performing a specific function. An action of a medical professional for treatment or diagnosis of a medical condition. The steps taken to implement a policy. |
| Procedural risk | A professionally recognized risk that a given procedure may induce functional impairment, injury, morbidity, or mortality |
| Procedural codes | The numeric or alphanumeric characters used to classify and report the medical procedures and services performed for patients. |
| Problem-oriented medical record (POMR) aka problem-oriented health record | Patient record in which clinical problems are defined and documented individually |
| Problem-oriented health record format | A health record documentation approach in which the physician defines each clinical problem individually |
| Problem list | A list of illnesses, injuries, and other factors that affect the health of an individual patient, usually identifying the time of occurrence or identification and resolution |
| Probationary period | A period of time in which the skills of a potential employee's work are assessed before he or she assumes full-time employment |
| Probate court | A state court that handles wills and settles estates |
| Peer review organization (PRO) | |
| Privileging process | The process of evaluating a physician's or other licensed independent practitioner's quality of medical practice and determining the services or procedures he or she is qualified to perform. |
| Privileged communication | The protection afforded to the recipients of professional services that prohibits medical practitioners, lawyers, and other professionals from disclosing the confidential information that they learn in their capacity as professional service provider |
| Privilege | The professional relationship between patients and specific groups of caregivers that affects the patient's health record and its contents as evicence; the services or procedures, based on training and experience, that an individual physician is qualifie |
| Private, unrestricted fee-for-service plan | A prepaid health insurance plan that allows beneficiaries to select private healthcare providers |
| Private right of action | The right of an injured person to secure redress for violation of his or her rights. A legal right to maintain an action growing out of a given transaction or state of facts and based thereon or a legal term pertaining to remedy and relief through judicia |
| Private law | The collective rules and principles that define the rights and duties of people and private businesses. |
| Private key | In cryptography, an asymmetric algorithm restricted to one entity |
| Private branch exchange (PBX) | A switching system for telephones on private extension lines that allows access to public telephone network |
| Privacy standards | Rules, conditions, or requirements developed to ensure the privacy of patient information |
| Privacy Rule | The federal regulations created to implement the privacy requirements of the simplification subtitle of HIPAA of 1996 effective in 2002; afforded patients certain rights to and about their protected health information. |
| Privacy Protection Study Commission | A commission established to review the weaknesses of the Privacy Act of 1974, evaluate the statute, and issue a report containing recommendations for its improvement to grant greater protections |
| Privacy Officer | A position mandated under the HIPAA Privacy Rule-covered entities must designate an individual to be responsible for developing and implementing privacy policies and procedures |
| Privacy (research) board | A group formed by a HIPAA-covered entity to review research studies where authorization waivers are requested and to ensure the HIPAA privacy rights of research subjects |
| Privacy Act of 1974 | A law that requires federal agencies to safeguard personally identifiable records and provides individuals with certain privacy rights |
| Privacy | The quality or state of being hidden form, or undisturbed by the observation or activities of other persons, or freedom from unauthorized intrusion; in healthcare-related contexts, the right of a patient to control disclosure of protected health informati |
| Priority focus process (PFP) | A process used by the Joint Commission to collect analyze, and create information about a specific organization being accredited in order to customize the accreditation process. |
| Priority focus area (PFA) | One of 14 areas that the JC considers vital in the successful operation of a hospital, includes processes, systems, and structures that have a substantial effect on patient care services. |
| Prior approval (authorization) aka precertification | process of obtaining approval from a healthcare insurance company before receiving healthcare services |
| Print file | Output from a computer system that generates a file containing an image of information that can be printed |
| Principal procedure | the procedure performed for the definitive treatment of a condition (as opposed to a procedure performed for diagnostic or exploratory purposes) or for care of a complication |
| Principal investigator | The individual with primary responsibility for the design and conduct of a research project |
| Principal diagnosis aka most significant diagnosis | the disease or condition that was present on admission, was the principal reason for admission, and received treatment or evaluation during the hospital stay or visit or the reason established after study to be chiefly responsible for occasioning the admi |
| Primary source system | An information system that is part of the overall clinical information system in which documentation is most commonly first entered or generated. |
| Primary source | An original work of a researcher who conducted an investigation. |
| Primary research | Data collected specifically for a study |
| Primary record of care aka health record | 1. Information relating to the physical or mental health or condition of an individual, as made by or on behalf of a health professional in connection with the care ascribed that individual 2. A medical record, health record, or medical chart that is a sy |
| Primary key aka key field | An explanatory notation that uniquely identifies each row in a database table |
| Primary insurer (payer) | The insurance company responsible for making the first payment on a claim |
| Primary data source (in healthcare) | a record developed by healthcare professionals in the process of providing patient care |
| Primary care provider (PCP) | Healthcare provider who provides, supervises, and coordinates the healthcare of a member; primary care providers can be family and general practitioners, internists, pediatricians, and obstetricians and gynecologists; other PCPs are nurse practitioners an |
| Primary care manager (PCM) | The healthcare provider assigned to a TRICARE beneficiary |
| Primary care | The continuous and comprehensive care provided at first contact with the healthcare provider in an ambulatory care setting |
| Primary analysis | The analysis of original research data by the researchers who collected them |
| Preventive controls | Internal controls implemented prior to an activity and designed to stop an error from happening |
| Prevalence study aka cross-sectional study | A biomedical research study in which both the exposure and the disease outcome are determined at the same time in each subject; See prevalence study |
| Prevalence rate | The proportion of people in a population who have a particular disease at a specific point in time or over a specified period of time |
| Pretty good privacy (PGP) | A type of encryption software that uses public key cryptology and digital signatures |
| Preterm neonate | Any neonate whose birth occurs through the end of the last day of the 38th week (266th day) following onset of the last menstrual period |
| Preterm infant | An infant with a birth weight between 1,000 and 2,499 grams and/or a gestation between 28 and 37 completed weeks |
| President's Information Technology Advisory Committee (PITAC) | A committee that advises the federal administration on information technology, including EHR interoperability issues; part of the President's Council of Advisors on Science and Technology (PCAST) |
| President's Council of Advisors on Science and Technology | An advisory group of the nation's leading scientists and engineers who directly advise the President and the Executive Office of the President; makes policy recommendations in the many areas where understanding of science, technology, and innovation is ke |
| Present value | A value that targets the current dollar investment and interest-rate needs to achieve a particular investment goal |
| Present on admission (POA) | A condition present at the time of inpatient admission |
| Prescription management | Cost-control measure that expands the use of a formulary to include patient education; electronic screening, alert, and decision-support tools; expert and referent systems; criteria for drug utilization; point-of-service order entry; electronic prescripti |
| Prepartum | Occurring prior to childbirth |
| Preoperative anesthesia evaluation | An assessment performed by an anesthesiologist to collect information on a patient's medical history and current physical and emotional condition that will become the basis of the anesthesia plan for the surgery to be performed |
| Premium | Amount of money that a policyholder or certificate holder must periodically pay an insurer in return for healthcare coverage |
| Pregnancy termination | The birth of a live-born or stillborn infant or the expulsion or extraction of a dead fetus or other products of conception from the mother |
| Pregnancy Discrimination Act | The federal legislation that prohibits discrimination against women affected by pregnancy, childbirth, or related medical conditions by requiring that affected women be treated the same as all other employees for employment-related purposes, including ben |
| Preferred term | In SNOMED CT, the description or name assigned to a concept that is used most commonly; in the UMNDS classification system, a representation of the generic product category, which is a list of preferred concepts that name devices |
| Preferred provider organization (PPO) | A managed care arrangement based on a contractual agreement between healthcare providers (professional and/or institutional) and employers, insurance carriers, or third-party administrators to provide healthcare services to a defined population of enrolle |
| Pre-existing condition | Any injury, disease, or physical condition occurring prior to an arbitrary date before the insured's enrollment date of coverage or any medical advice, diagnosis, care, or treatment that was recommended or received. Healthcare coverage may be denied for a |
| Preemption | In law, the principle that a statute at one level supercedes or is applied over the same or similar statute at a lower level (for example, the federal HIPAA privacy provisions trump the same or similar state law except when state law is more stringent) |
| Predictive modeling | A process used to identify patterns that can be used to predict the odds of a particular outcome based on the observed data |
| Predecessor | A task that affects the scheduling of a successor task in a dependency relationship |
| Precision factor | The definitive tolerable error rate to be considered in calculations of productivity standards |
| Precertification aka prior approval (authorization) | Control number issued when a healthcare service is approved |
| Preadmission utilization review | A type of review conducted before a patient's admission to an acute care facility to determine whether the planned service (intensity of service) or the patient's condition (severity of illness) warrants care in an inpatient setting |
| Preadmission Screening Assessment and Annual Resident Review (PASARR) | A screening process for mental illness and mental retardation that must be completed prior to a prospective resident's admission to the long-term care facility |
| Preadmission review aka | prior approval (authorization), preadmission certification |
| Practice management system (PMS) | A type of software that automates a physician office's patient appointment scheduling, registration, billing, and payroll functions |
| Practice guidelines | Protocols of care that guide the clinical care process |
| Practice expenses (PE) | Element of the relative value unit (RVU) that covers the physician's overhead costs, such as employee wages, office rent, supplies, and equipment. There are two types, facility and nonfacility |
| physician quality reporting system (PQRS) | An incentive payment system for eligible professionals who satisfactorily report data on quality measures for covered professional services furnished to Medicare beneficiaries; formerly known as the Physician Quality Reporting Initiative (PQRI) |
| Periodic performance review aka physician payment reform (PPR) | An organizational self-assessment conducted at the halfway point between triennial on-site accreditation surveys conducted by the Joint Commission |
| Per patient per month (PPPM) | A type of managed care arrangement by which providers are paid a fixed fee in exchange for supplying all of the healthcare services an enrollee needs for a specified period of time (usually one month but sometimes one year); See per member per month (PMPM |
| Patient Protection and affordable care act (PPACA) | A federal statute that was signed into law on March 23, 2010. Along with the Health Care and Education Reconciliation Act of 2010 (signed into law on March 30, 2010), the Act is the product of the healthcare reform agenda of the Democratic 111th Congress |
| Potential compensable event (PCE) | An event (for example, an injury, accident, or medical error) that may result in financial liability for a healthcare organization, for example, an injury, accident, or medical error |
| Post-term neonate | Any neonate whose birth occurs from the beginning of the first day (295th day) of the 43rd week following onset of the last menstrual period |
| Postpartum | Occurring after childbirth |
| Postoperative infection rate | The number of infections that occur in clean surgical cases for a given time period divided by the total number of operations within the same time period |
| Postoperative death rate | The ratio of deaths within 10 days after surgery to the total number of operations performed during a specified period of time |
| Postoperative anesthesia record | Health record documentation that contains information on any unusual events or complications that occurred during surgery as well as information on the patient's condition at the conclusion of surgery and after recovery from anesthesia |
| Postneonatal mortality rate | The number of deaths of persons aged 28 days up to, but not including, one year during a given time period divided by the number of live births for the same time period |
| Postneonatal death | The death of a live-born infant from 28 days to the end of the first year of life (364 days, 23 hours, 59 minutes from the moment of birth) |
| Postmortem examination aka autopsy | The postmortem examinations of the organs and tissues of a body to determine the cause of death or pathological conditions |
| Postdischarge plan of care (from long-term care facility) | A care plan used to help a resident discharged from the long-term care facility to adapt to his or her new living arrangement |
| Post-acute care | Care provided to patients who have been released from an acute care facility to recuperate at home |
| Point-of-service (POS) healthcare insurance plan | A type of managed care plan in which enrollees are encouraged to select healthcare providers from a network of providers under contract with the plan but are also allowed to select providers outside the network and pay a larger share of the cost; See open |
| Positivism | A philosophy of research that assumes that there is a single truth across time and place and that researchers are able to adopt a neutral, unbiased stance and establish causation; See quantitative approach |
| Positive relationship | A relationship in which the effect moves in the same direction; Also called direct relationship |
| Position power | A situation in contingency in which the leader is perceived as having the authority to give direction |
| Place of service or point of service (POS) | A two-digit code used in box 24b of the CMS-1500 claim form to describe the location where the service was performed |
| Population variance | Average of the squared deviations from the population mean |
| Population health dimension (PHD) | One of three dimensions of the National Health Information Infrastructure privacy concept that addresses protecting and promoting the health of the community |
| Population health | The capture and reporting of healthcare data that are used for public health purposes. It allows the healthcare provider to report infectious diseases, immunizations, cancer, and other reportable conditions to public health officials |
| Population-based statistics | Statistics based on a defined population rather than on a sample drawn from the same population |
| Population-based registry | A type of registry that includes information from more than one facility in a specific geopolitical area, such as a state or region |
| Population (as related to research) | The universe of data under investigation from which a sample is taken |
| Polymorphic virus | A type of computer virus that can change its form after infecting a file |
| Policyholder | An individual or entity that purchases healthcare insurance coverage; See certificate holder; insured; member; subscriber |
| Policies | 1. Governing principles that describe how a department or an organization is supposed to handle a specific situation or execute a specific process 2. Binding contracts issued by a healthcare insurance company to an individual or group in which the company |
| Point-of-service (POS) healthcare insurance plan | A type of managed care plan in which enrollees are encouraged to select healthcare providers from a network of providers under contract with the plan but are also allowed to select providers outside the network and pay a larger share of the cost; See open |
| Point-of-care review aka open-record review | A review of the health records of patients currently in the hospital or under active treatment; part of the Joint Commission survey process |
| Point-of-care information system | A computer system that captures data at the location (for example, bedside, exam room, or home) where the healthcare service is performed |
| Point-of-care documentation | A system whereby information is entered into the health record at the time and location of service |
| Point-of-care charting | A system whereby information is entered into the health record at the time and location of service |
| Point of care (POC) | The place or location where the physician administers services to the patient |
| Point method | A method of job evaluation that places weight (points) on each of the compensable factors in a job whereby the total points associated with a job establish its relative worth and jobs that fall within a specific range of points fall into a pay grade with |
| Perioperative nursing dataset (PNDS) | A data set developed by the Association of Perioperative Registered Nurses to identify the perioperative experience of the patient from preadmission to discharge |
| Plug-and-play | An adapter card hardware that sets connections through software rather than hardware, making hardware easier to install; a computer system's ability to detect and operate a new device as soon as it is added (for example, wireless mouse) |
| Platform | The combination of the hardware and operating system on which an application program can run |
| Plan of care (POC) | A term referring to Medicare home health services for homebound beneficiaries that must be delivered under a plan established by a physician |
| Planning stage | In performance management, the stage during which specific goals and performance standards are defined |
| Planning | An examination of the future and preparation of action plans to attain goals; one of the four traditional management functions |
| Planned redundancy | A disaster recovery strategy in which information technology operations are duplicated at other locations |
| Plan-do-study-act (PDSA) cycle | A performance improvement model designed specifically for healthcare organizations |
| Plan-do-check-act (PDCA) cycle | A performance improvement model developed by Walter Shewhart, but popularized in Japan by W. Edwards Deming |
| Plaintiff | The group or person who initiates a civil lawsuit |
| Plain text | A message that is not encrypted; a form of text that does not support text formatting such as bold, italic, or underline; most efficient way to store text |
| placebo | A medical intervention or medication with no active ingredients |
| Pixel | An abbreviation for the term picture element, which is defined by many tiny bits of data or points |
| Provider identification number (PIN) | |
| Pilot study | A trial run on a smaller scale. also called feasibility study |
| Pie graph aka pie chart | A graphic technique in which the proportions of a category are displayed as portions of a circle (like pieces of a pie); used to show the relationship of individual parts to the whole |
| piece-rate incentive | An adjustment of the compensation paid to a worker based on exceeding a certain level of output |
| Pediatric intensive care unit (PICU) | |
| Picture archiving and communication system (PAC) | An integrated computer system that obtains, stores, retrieves, and displays digital images (in healthcare, radiological images) |
| Pictogram | A graphic technique in which pictures are used in the display of data |
| Pick list | A list of options that appear below an item when clicked which a user selects to complete the computer entry; See also drop-down menu |
| Peripherally inserted central venous catheter (PICC) | |
| Performance improvement (PI) | Cellular, tissue, or organ processes or functions altered by drugs |
| Physiological signal processing systems | Systems that store vector graphic data based on the human body's signals and create output based on the lines plotted between the signals' points |
| Physician work (WORK) | Component or element of the relative value unit (RVU) that should cover the physician's salary. This work is the time the physician spends providing a service and the intensity with which that time is spent. The four elements of intensity are mental effor |
| physician's order | A physician's written or verbal instructions to the other caregivers involved in a patient's care |
| physician's certification | A statement from a physician confirming a Medicare-eligible resident's need for long-term care services |
| Physician query process policy | A policy that addresses requests from physicians for additional information as part of the coding and reimbursement process |
| Physician query process | The process by which questions are posed to a provider to obtain additional, clarifying documentation to improve the specificity and completeness of the data used to assign diagnosis and procedure codes in the patient's health record |
| Physician quality reporting system (PQRS) | An incentive payment system for eligible professionals who satisfactorily report data on quality measures for covered professional services furnished to Medicare beneficiaries; formerly known as the Physician Quality Reporting Initiative (PQRI) |
| Physician profiling | A type of quality improvement and utilization management software that enables provider and payer organizations to monitor how and with what resources physicians are treating patients |
| Physician payment reform (PPR) | A legislative change in the way Medicare pays for physician services required by the Omnibus Budget Reconciliation Act of 1989, which includes a national fee schedule based on a resource-based relative value scale with geographic adjustments for differenc |
| Physician-patient relationship | A relationship in which the physician trusts the patient to be forthcoming and honest in providing the information necessary for diagnosis and treatment, and the patient trusts the physician to use that information responsibly, in his or her best interest |
| Physician-patient privilege | The legal protection from confidential communications between physicians and patients related to diagnosis and treatment being disclosed during civil and some misdemeanor litigation |
| Physician index | A list of patients and their physicians usually arranged according to the physician code numbers assigned by the healthcare facility |
| Physician-hospital organization (PHO) | An integrated delivery system formed by hospitals and physicians (usually through managed care contracts) that allows for cooperative activity but permits participants to retain some level of independence |
| Physician extender (PE) | A professional such as a physician assistant or nurse practitioner who 'extends' the services of the physician to ensure continuity of care if issues or concerns arise in the long-term care setting and the physician cannot be present |
| Physician contingency reserve aka withold | |
| Physician champion | An individual who assists in communicating and educating medical staff in areas such as documentation procedures for accurate billing and appropriate EHR processes |
| Physician care group (PCG) | Type of outpatient prospective payment method for physician services in which patients are classified into similar, homogenous categories |
| Physician assistant (PA) | A healthcare professional licensed to practice medicine with physician supervision |
| Physical therapy (PT) | The field of study that focuses on physical functioning of the resident on a physician-prescribed basis |
| Physical status modifier | The two-digit code (P1-P6) attached to a CPT code to describe the patient's condition and therefore the complexity of the anesthesia service |
| Physical safeguards | Measures such as locking doors to safeguard data and various media from unauthorized access and exposures; a set of four standards defined by the HIPAA Security Rule, including facility access controls, workstation use, workstation security, and device an |
| Physical restraint | Any manual or mechanical device, material, or equipment attached or adjacent to a resident's body that restricts freedom of movement and prevents the resident's normal access to his or her own body |
| Physical examination report | Documentation of a physician's assessment of a patient's body systems |
| Physical data repository | A repository organized into data fields, data records, and data files, storing structured, discrete, clinical, administrative, and financial data as well as unstructured, patient free-text, bitmapped, real audio, streaming video, or vector graphic data |
| Physical data model | The lowest level of data model with the lowest level of abstraction |
| Physical access controls | 1. Security mechanisms designed to protect an organization's equipment, media, and facilities from physical damage or intrusion 2. Security mechanisms designed to prevent unauthorized physical access to health records and health record storage areas |
| Personal health record (PHR) | |
| Photochemotherapy | The combination of light and chemical therapy in treating skin diseases |
| Personal health dimension (PHD) | |
| Pharmacy information system | System that assists care providers in ordering, allocating, and administering medication; focuses on patient safety issues, especially medication errors and providing optimal patient care |
| Pharmacy benefits manager (PBM) | The vendor selected by the Bureau of Workers' Compensation to process outpatient medication bills submitted electronically |
| Pharmacy and therapeutics (P and T) committee | The multidisciplinary committee that oversees and monitors the drugs and therapeutics available for use, the administration of medications and therapeutics, and the positive and negative outcomes of medications and therapeutics used in a healthcare organi |
| Phacofragmentation | A technique whereby the lens is broken into fragments by a mechanical means or by ultrasound |
| Phacoemulsification | A cataract extraction technique that uses ultrasonic waves to fragment the lens and aspirate it out of the eye |
| Past, family, and social history (PFSH) | The patient's past experience with illnesses, hospitalizations, operations, injuries, and treatments; a review of medical events in the patient's family, including diseases that may be hereditary or place the patient at risk; age-appropriate review of pas |
| Petition for writ of certiorari | A document filed with the US Supreme Court, asking for a review of a lower court's findings |
| Peter Principle | A cynical belief that employees will advance to their highest level of competence, and then be promoted to their level of incompetence where they will remain (named after the 1993 book by Laurence J. Peter) |
| PERT chart aka program evaluation review technique chart | A project management tool that diagrams a project's time lines and tasks as well as their interdependencies |
| Personal/unique identifier | The unique name or numeric identifier that sets apart information for an individual person for research and administrative purposes |
| Personal health dimension (PHD) | One of three dimensions of the national health information network privacy concept that supports individuals in managing their own wellness and healthcare decision making |
| Personal digital assistant (PDA) | A handheld microcomputer, without a hard drive, that is capable of running applications such as e-mail and providing access to data and information, such as notes, phone lists, schedules, and laboratory results, primarily through a pen device |
| Permanent variance | A financial term the refers to the difference between the budgeted amount and the actual amount of a line item that is not expected to reverse itself during a subsequent period |
| Permanent national codes | HCPCS level II codes that provide a standard coding system managed by private and public insurers |
| Permanent employee | A person who is employed for an indefinite, ongoing period of time, typically long-term |
| Permanence | The quality of being in a constant, continuous state |
| Peritoneal dialysis | A continuous or intermittent procedure in which dialyzing solution is introduced into and removed from the peritoneal cavity to cleanse the body of metabolic waste products |
| Peripheral | Any hardware device connected to a computer (for example, a keyboard, mouse, or printer) |
| Perioperative Nursing Dataset (PNDS) | A data set developed by the Association of Perioperative Registered Nurses to identify the perioperative experience of the patient from preadmission to discharge |
| Periodic performance review (PPR) | An organizational self-assessment conducted at the halfway point between triennial on-site accreditation surveys conducted by the Joint Commission |
| Perinatal death | An all-inclusive term that refers to both stillborn infants and neonatal deaths |
| Performing | The fourth of the four steps in forming a functional team, at which point each team member is in a position to work toward achieving the team's stated goals |
| Performance tests aka ability (achievement) tests | Tests used to assess the skills an individual already possesses; Also called performance tests |
| Performance standards | The stated expectations for acceptable quality and productivity associated with a job function |
| Performance review | An evaluation of an employee's job performance; See performance evaluation |
| Performance measure/measurement system | System designed to improve performance by providing feedback on whether goals have been met |
| performance indicator | A measure used by healthcare facilities to assess the quality, effectiveness, and efficiency of their services |
| Performance improvement (PI) team | Members of the healthcare organization who have formed a functional or cross-functional group to examine performance issues and make recommendations for improvement |
| Performance improvement council | The leadership group that oversees performance improvement activities in healthcare organizations |
| Performance evaluation | A review of an employee's job performance; See performance review |
| Performance counseling | Guidance provided to an individual in an attempt to improve his or her work performance |
| Per-diem reimbursement | A reimbursement system based on a set payment for all of the services provided to a patient on one day rather than on the basis of actual charges |
| Per-diem rate | The cost per day derived by dividing total costs by the number of inpatient care days |
| Per diem (per day) | Type of prospective payment method in which the third-party payer reimburses the provider a fixed rate for each day a covered member is hospitalized |
| Percentage of occupancy aka inpatient bed occupancy rate | The total number of inpatient service days for a given time period divided by the total number of inpatient bed count days for the same time period; Also called percentage of occupancy |
| Percentage | A value computed on the basis of the whole divided into 100 parts |
| Per case | A method of billing in which services are charged on the basis of the total service being rendered rather than by each component of the service (for example, charging for transplantation services when the organ has been procured, the transplant has been m |
| Payment error prevention (PEPP) | Payment compliance program established under the Sixth Scope of Work to help healthcare facilities identify simple mistakes causing payment errors; monitored by Quality Improvement Organizations (QIOs) |
| Partial episode payment adjustment (PEP) | A reduced episode payment that may be based on the number of service days in an episode |
| Pending | A condition during which a facility waits for payment after a bill is dropped |
| Percutaneous endoscopic gastrostomy tube (PEG) | |
| Peer review organization (PRO) | Until 2002, a medical organization that performed a professional review of medical necessity, quality, and appropriateness of healthcare services provided to Medicare beneficiaries; now called quality improvement organization (QIO) |
| Peer-reviewed journal | A type of professional or scientific journal for which content experts evaluate articles prior to publication; See refereed journal |
| Peer review | 1. Review by like professionals, or peers, established according to an organization's medical staff bylaws, organizational policy and procedure, or the requirements of state law; the peer review system allows medical professionals to candidly critique and |
| Pediatric service | A service that provides diagnostic and therapeutic services for patients at age of minority |
| Pediatric patient | A patient that is at an age of minority as defined by state law at the time of discharge |
| Patient care unit (PCU) | An organizational entity of a healthcare facility organized both physically and functionally to provide care |
| PC Pricer | Software module in a Medicare claim-processing system, specific to certain benefits, used in pricing claims and calculating payment rates and payments, most often under prospective payment systems |
| withhold | Portion of providers' capitated payments that managed care organizations deduct and hold in order to create an incentive for efficient or reduced utilization of healthcare services; Also called physician contingency reserve |
| withhold | Portion of providers' capitated payments that managed care organizations deduct and hold in order to create an incentive for efficient or reduced utilization of healthcare services; Also called physician contingency reserve |
| Password crackers | Software programs used to identify an unknown or forgotten password |
| password | A series of characters that must be entered to authenticate user identity and gain access to a computer or specified portions of a database |
| Pass-through | Exception to the Medicare prospective payment systems (PPSs) for a high-cost service. The exception minimizes the negative financial impact of the lump-sum payments of the PPSs. Pass-throughs are not included in the PPSs and are passed through to cost-bas |
| Part-time employee | An employee who works less than the full-time standard of 40 hours per week, 80 hours per two-week period, or 8 hours per day |
| Partnership | The business venture of two or more owners for whom the profits represent the owners' personal income |
| Participating physicians (PARs) | Physicians who sign an agreement with Medicare to accept assignment for all services provided to Medicare beneficiaries for the duration of the agreement |
| Participant observation | A research method in which researchers also participate in the observed actions |
| Partial mastectomy | The partial removal of breast tissue, leaving the breast nearly intact; sometimes called a lumpectomy |
| Partial hospitalization | A limited patient stay in the hospital setting, typically as part of a transitional program to a less intense level of service; for example, psychiatric and drug and alcohol treatment facilities that offer services to help patients reenter the community, |
| Partial episode payment (PEP) adjustment | A reduced episode payment that may be based on the number of service days in an episode |
| Par level | The accepted, standard inventory level for all supplies and equipment in an organization |
| Pareto chart | A bar graph that includes bars arranged in order of descending size to show decisions on the prioritization of issues, problems, or solutions |
| Parametric technique | A type of statistical procedure that is based on the assumption that a variable is normally distributed in a population |
| Parallel work division | A type of concurrent work design in which one employee does several tasks and takes the job from beginning to end |
| Paradigm | A philosophical or theoretical framework within which a discipline formulates its theories and makes generalizations |
| Panel interview | An interview format in which the applicant is interviewed by several interviewers at the same time |
| Palliative care | A type of medical care designed to relieve the patient's pain and suffering without attempting to cure the underlying disease |
| Packet switching | An information transmission system in which data are encoded into short units (packets) and sent through an electronic communications network |
| Packaging | A payment under the Medicare outpatient prospective payment system that includes items such as anesthesia, supplies, certain drugs, and the use of recovery and observation rooms |
| Package Code | The part of the National Drug Code that identifies package size |
| Owner's equity | The value of the investment in an organization by its owners |
| Overlay | Situation in which a patient is issued a medical record number that has been previously issued to a different patient |
| Overlap | Situation in which a patient is issued more than one medical record number from an organization with multiple facilities |
| Overhead costs | The expenses associated with supporting but not providing patient care services |
| Overcoding | The practice of assigning more codes than needed to describe a patient's condition. Some instances of overcoding may be contrary to the guidance provided in the Official Coding Guidelines |
| Outsourcing firm | A company that enters into a contract with a healthcare organization to perform services such as clinical coding or transcription |
| Outsourcing | The hiring of an individual or a company external to an organization to perform a function either on site or off site |
| Outputs | The outcomes of inputs into a system (for example, the output of the admitting process is the patient's admission to the hospital) |
| Outpatient visit | A patient's visit to one or more units located in the ambulatory services area (clinic or physician's office) of an acute-care hospital in which an overnight stay does not occur |
| Outpatient unit | A hospital-based ambulatory care facility organized into sections (clinics) whose number depends on the size and degree of departmentalization of the medical or clinic staff, available facilities, type of service needed in the community, and the needs of |
| Outpatient Service Mix Index (SMI) | The sum of the weights of ambulatory payment classification groups for patients treated during a given period divided by the total volume of patients treated. |
| Outpatient prospective payment system (OPPS) | The Medicare prospective payment system used for hospital-based outpatient services and procedures that is predicated on the assignment of ambulatory payment classifications |
| Outpatient coder | An individual responsible for assigning ICD-9-CM and CPT/HCPCS codes to ambulatory surgery, emergency department cases, or outpatient ancillary clinic visits |
| Outpatient code editor (OCE) | A software program linked to the Correct Coding Initiative that applies a set of logical rules to determine whether various combinations of codes are correct and appropriately represent the services provided; See editor |
| Outpatient | A patient who receives ambulatory care services in a hospital-based clinic or department |
| Out-of-pocket expenses | Healthcare costs paid by the insured (for example, deductibles, copayments, and coinsurance) after which the insurer pays a percentage (often 80 or 100 percent) of covered expenses |
| Out-of-pocket | Payment made by the policyholder or member |
| Outlier threshold (OT) | The upper range (threshold) in length of stay before the case becomes a day outlier |
| Outlier payment | A payment made in addition to a full-episode payment when the cost of the services exceeds a fixed-loss threshold in the Medicare acute care prospective payment system |
| Outlier | 1. A case in a prospective payment system with unusually long lengths of stay or exceptionally high costs (day outlier or cost outlier, respectively) 2. An extreme statistical value that falls outside the normal range |
| Outguide | A device used in paper-based health record systems to track the location of records removed from the file storage area |
| Outcomes monitoring aka outcome management aka outcomes management | The process of systematically tracking a patient's clinical treatment and responses to that treatment, including measures of morbidity and functional status, for the purpose of improving care; |
| Outcomes assessment | An evaluation that measures the actual outcomes of patient care and service against predetermined criteria (expected outcomes), based on the premise that care is delivered in order to bring about certain results; Also called outcomes analysis |
| Outcomes and effectiveness research (OER) | A type of research performed to explain the end results of specific healthcare practices and interventions |
| Outcomes and Assessment Information Set (OASIS) | A standard core assessment data tool developed to measure the outcomes of adult patients receiving home health services under the Medicare and Medicaid programs |
| Outcome measures | 1. The process of systematically tracking a patient's clinical treatment and responses to that treatment, including measures of morbidity and functional status, for the purpose of improving care 2. A measure that indicates the result of the performance (o |
| Outcome indicator | A measurement of the end results of a clinical process (for example, complications, adverse effects, patient satisfaction) for an individual patient or a group of patients within a specific diagnostic category; See outcome measures |
| Outcome | 1. The end result of healthcare treatment, which may be positive and appropriate or negative and diminishing 2. The performance (or nonperformance) of one or more processes, services, or activities by healthcare providers |
| Other urban area | An urban area with a population of one million residents or fewer |
| Other diagnoses | All conditions (recorded to the highest documented level of specificity) that coexist at the time of admission, develop subsequently, or affect the treatment received and/or length of stay |
| Osteopath | A physician licensed to practice in osteopathy (a system of medical practice that is based on the manipulation of body parts as well as other therapies) |
| operations support system (OSS) | |
| Occupational Safety and Health Act of 1970 (OSHA of 1970) | The federal legislation that established comprehensive safety and health guidelines for employers |
| Occupational Safety and Health Administration (OSHA) | Ensures safe and healthful working conditions for working men and women by setting and enforcing standards and by providing training, outreach, education, and assistance |
| ORYX initiative | The Joint Commission's initiative that supports the integration of outcomes data and other performance measurement data into the accreditation process; often referred to as ORYX |
| Operation Restore Trust (ORT) | |
| Orion Project | The Joint Commission's initiative designed to assess accreditation models, develop a continuous accreditation process, and test alternative processes for reporting survey findings to hospitals |
| Orientation | A set of activities designed to familiarize new employees with their jobs, the organization, and its work culture |
| Organizing | The process of coordinating something, such as activities |
| Organized Healthcare Arrangement (OHCA) | An agreement characterized by more than one covered entity who share PHI to manage and benefit their common enterprise and are recognized by the public as a single entity |
| Organizational pull model | A model in which the organization views information systems technology as the means to enable people in the organization to work more efficiently and effectively |
| Organizational lifeline | A line drawing of important historical events in the life of an organization; used for organizational development intervention reflecting on historical trends |
| Organizational development (OD) | The application of behavioral science research and practices to planned organizational change |
| Organizational chart | A graphic representation of an organization's formal reporting structure |
| Organization | The planned coordination of the activities for more than one person for the achievement of a common purpose or goal |
| Ordinal scale of measurement | Measurement scale that consists of separate categories with separate names ranked in terms of magnitude |
| Ordinal-level data | Data with inherent order and with higher numbers usually associated with higher values; Also called ordinal data; ranked data |
| Ordinal data | A type of data that represents values or observations that can be ranked or ordered; See ordinal-level data |
| Orders for restraint or seclusion | Physician's orders for physical or pharmaceutical restraint or seclusion to protect the patient or others from harm |
| Order entry | The use of a computer and decision support to record and initiate the transmission of a physician's order |
| Object request broker (ORB) | |
| Orange book | The common name for the US Department of Defense document that defines the trusted computer system evaluation criteria, from which many of the security criteria for healthcare systems are being drawn |
| Operating room procedure (OR procedure) | |
| Opt-out with exceptions | Sets the defaults for health information of patients to be included, but the patient can opt out completely or allow only select data to be included |
| Opt-in with restrictions | A type of HIE model in which the default is set where no patient health information is automatically made available; patients must define what information is to be sent, who it is sent to, and for what purposes the information may be used |
| Opt-in/Opt-out | A type of HIE model that sets the default for health information of patients to be included automatically, but the patient can opt out completely |
| Optimization (as related to clinical coding) | The process of thoroughly reviewing the health record to identify all procedures performed and services rendered by the physician to ensure accurate and complete coding for optimum reimbursement |
| Optical imaging technology | The process by which information is scanned onto optical disks |
| Optical image-based system | A health record system in which information is created initially in paper form and then scanned into an electronic system for storage and retrieval |
| Optical character recognition (OCR) technology | A method of encoding text from analog paper into bitmapped images and translating the images into a form that is computer readable |
| Opportunity for improvement | A healthcare structure, product, service, process, or outcome that does not meet its customers' expectations and, therefore, could be improved |
| Operative report | A formal document that describes the events surrounding a surgical procedure or operation and identifies the principal participants in the surgery |
| Operations support systems (OSS) | An information system that facilitates the operational management of a healthcare organization such as telecommunications or bed boards and patient flow; varies by organization |
| Operations research (OR) | A scientific discipline primarily begun around the World War II era that seeks to apply the scientific method and mathematical models to the solution of a variety of management decision problems |
| Operations management | The application of mathematical and statistical techniques to production and distribution efficiency |
| Operation Restore Trust | A 1995 joint effort of the Department of Health and Human Services (HHS), Office of the Inspector General (OIG), the Centers for Medicare and Medicaid Services (CMS), and the Administration of Aging (AOA) to target fraud and abuse among healthcare provide |
| Operation index | A list of the operations and surgical procedures performed in a healthcare facility, which is sequenced according to the code numbers of the classification system in use |
| Operational plan | The short-term objectives set by an organization to improve its methods of doing business and achieve its planned outcomes |
| Operational decision making | A process for addressing problems that come up in the day-to-day operation of a business unit or the day-to-day execution of a work task |
| Operational budget | A type of budget that allocates and controls resources to meet an organization's goals and objectives for the fiscal year |
| Operating system | The principal piece of software in any computer system, which consists of a master set of programs that manage the basic operations of the computer |
| Operating room (OR) procedure | Procedure that the physician panel classifies as occurring in the operating room in most hospitals; presence of an OR procedure groups a case to a surgical diagnosis-related group (DRG) |
| Operating room (OR) | The area in a healthcare facility that is equipped and staffed to provide facilities and personnel for the performance of surgical procedures |
| Operating clinician identification | The unique national identification number assigned to the clinician who performed the principal procedure |
| Operating budget | The budget that summarizes the anticipated expenses for a department's routine, day-to-day operations |
| Open system | A system which permits other parties to produce products that interoperate with it; a computer is an open system |
| Open records laws | Laws that define what information is subject to public disclosure and are used to deny FOIA requests that include PHI; Also called freedom of information laws; public records |
| Open-record review | A review of the health records of patients currently in the hospital or under active treatment; part of the Joint Commission survey process |
| Open record | The health record of a patient who is still receiving services in the facility |
| Opening conference | A meeting conducted at the beginning of the Joint Commission accreditation site visit during which the surveyors outline the schedule of activities and list any individuals whom they would like to interview |
| Object-oriented database management system (OODBMS) | |
| Object-oriented database (OODB) | |
| Ontology | A common vocabulary organized by meaning, allowing for an understanding of the structure of descriptive information that facilitates a specific topic or domain |
| On-the-job training | A method of training in which an employee learns necessary skills and processes by performing the functions of his or her position |
| Online/real-time transaction processing (OLTP) | The real-time processing of day-to-day business transactions from a database; See online analytical processing |
| Online/real-time analytical processing (OLAP) aka online analytical | A data access architecture that allows the user to retrieve specific information from a large volume of data; See online transaction processing |
| Online analytical processing (OLAP) engine | An optimized query generator that can retrieve the correct information from the warehouse to accommodate what-if queries |
| One-to-one relationship | A relationship that exists when an instance of an entity is associated with only one instance of another entity, and vice versa |
| One-to-many relationship | A relationship that exists when one instance of an entity is associated with multiple instances of another entity |
| One-tailed hypothesis | An alternative hypothesis in which the researcher makes a prediction in one direction |
| See Office of the National Coordinator for Health Information Technology (ONC) | |
| Osteopathic manipulative treatment (OMT) | |
| Omnibus Budget Reconciliation Act (OBRA) of 1989 | The federal legislation that mandated important changes in the payment rules for Medicare physicians; specifically, the legislation that requires nursing facilities to conduct regular patient assessments for Medicare and Medicaid beneficiaries |
| Omnibus Budget Reconciliation Act (OBRA) of 1987 | Federal legislation passed in 1987 that required the Health Care Financing Administration (now renamed the Centers for Medicare and Medicaid Services) to develop an assessment instrument (called the resident assessment instrument) to standardize the colle |
| Omaha System | A research-based taxonomy designed to generate data following routine client care |
| Offshoring | Outsourcing jobs to countries overseas, wherein local employees abroad perform jobs that domestic employees previously performed |
| Office of the National Coordinator for Health Information Technology (ONC) | Office of the National Coordinator for Health Information Technology (ONC) |
| Office of the Inspector General (OIG) Workplan | Yearly plan released by the OIG that outlines the focus for reviews and investigations in various healthcare settings |
| Office of the Inspector General (OIG) | Mandated by Public Law 95-452 (as amended) to protect the integrity of Department of Health and Human Services (HHS) programs, as well as the health and welfare of the beneficiaries of those programs. The OIG has a responsibility to report both to the Sec |
| Office of Research Integrity (ORI) | Promotes integrity in biomedical and behavioral research supported by the US Public Health Service (PHS) at about 4,000 institutions worldwide. ORI monitors institutional investigations of research misconduct and facilitates the responsible conduct of res |
| Office of Management and Budget (OMB) | The core mission of OMB is to serve the President of the United States in implementing his vision across the Executive Branch. OMB is the largest component of the Executive Office of the President. It reports directly to the President and helps a wide ran |
| Office for Human Research Protections (OHRP) | Provides leadership in the protection of the rights, welfare, and well-being of subjects involved in research conducted or supported by the US Department of Health and Human Services (HHS). OHRP helps ensure this by providing clarification and guidance, d |
| Office for Civil Rights (OCR) | Department in HHS responsible for enforcing civil rights laws that prohibit discrimination on the basis of race, color, national origin, disability, age, sex, and religion by healthcare and human services entities over which OCR has jurisdiction, such as |
| Odds ratio | A relative measure of occurrence of an illness; the odds of exposure in a diseased group divided by the odds of exposure in a nondiseased group |
| Occurrence screening | A risk management technique in which the risk manager reviews the health records of current and discharged hospital inpatients with the goal of identifying potentially compensable events; Also called generic screening |
| Occurrence report | A structured data collection tool that risk managers use to gather information about potentially compensable events; Also called incident report |
| Occupational therapy (OT) | A treatment that uses constructive activities to help restore the resident's ability to carry out needed activities of daily living and improves or maintains functional ability |
| Occupational safety and health record | A record kept on an employee as part of employment that contains any and all information related to such items as medical tests, drug tests, examinations, physical abilities, immunizations, screenings required by law, biohazardous exposure, and physical l |
| Occupational health services | Health services involving the physical, mental, and social well-being of individuals in relation to their work and working environment |
| Occupational health | The degree to which an employee is able to function at an optimum level of well-being at work as reflected by productivity, work attendance, disability compensation claims, and employment longevity |
| Occupation | The employment, business, or course of action in which the patient is engaged |
| Occlusion | Completely closing an orifice or the lumen of a tubular body part |
| Occasion of service | A specified identifiable service involved in the care of a patient that is not an encounter (for example, a lab test ordered during an encounter) |
| Observation patient | A patient who presents with a medical condition with a significant degree of instability and disability and who needs to be monitored, evaluated, and assessed to determine whether he or she should be admitted for inpatient care or discharged for care in a |
| Observational study | An epidemiological study in which the exposure and outcome for each individual in the study is observed |
| Observational research | A method of research in which researchers obtain data by watching research participants rather than by asking questions |
| Observation | Service in which providers observe and monitor a patient to decide whether the patient needs to be admitted to inpatient care or can be discharged to home or an outpatient area, usually charged by the hour |
| Object request broker (ORB) | The messenger at the heart of the object-oriented framework that acts as a relay station between client and server |
| Object-relational database | A type of database (both object-oriented and relational) that stores both objects and traditional tables |
| Object-oriented framework | A new way of programming and representing data that uses commands that act as small, self-contained instructional units that may be combined in various ways to produce larger programs |
| Object-oriented database management system (OODBMS) | A specific set of software programs used to implement an object-oriented database |
| Object-oriented database (OODB) | A type of database that uses commands that act as small, self-contained instructional units (objects) that may be combined in various ways |
| Objectivity | An accounting concept in which assets are classified at historical cost or current value |
| Objective | A statement of the end result expected, stated in measurable terms, usually with a time limitation (deadline date) and often with a cost estimate or limitation |
| Object | The basic component in an object-oriented database that includes both data and their relationships within a single structure |
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