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HIMT1400 & HIMT 1100
Data, Structure, Content and Standards
| Question | Answer |
|---|---|
| Facts that are not interpreted or processed. Numbers, letters, images, symbols and sounds. | DATA |
| Establishing a standard method for collecting and reporting individual data elements so data can be easily compared. | DATA SET |
| Health facts collected on the patient. | Healthcare Data |
| Factual Data that has been collected, combined, analyzed, interpreted that provide meaning. | Information |
| Maintained by the National Committee for Quality Assurance (NCQA). Compares performance of managed care plans. | HEDIS-Health Plan Employer Data and Information |
| Collection of descriptive data objects in a data model, include: data elements, definitions of data elements, attributes of data elements, specification for the size of data fields, description of data views from users, location -where is the data stored. | Data Dictionary |
| Minimum Data Set | MDS |
| Long-term care facilities (participation is mandatory if participates in Medicare and Medicaid) | Minimum Data Set (MDS) |
| Core set of screening elements for comprehensive assessment of LTCF (long term care facilities) residents; used to create resident assessment protocols (RAPs). RAVEN (Resident assessment and validation and entry) data-entry system is used. Maintained by CMS. Standardizes communication about resident problems and conditions. | Minimum Data Set (MDS) |
| Used in 24 hour, hospital based emergency departments. Participation is voluntary. Maintained by the CDC. Uniform data-element specifications for describing single ED patient encounters. | DEEDS (Data Elements for Emergency Department Systems) |
| Data Elements for Emergency Department Systems | DEEDS |
| EMDS is the abbreviation for | Essential Medical Data Set |
| Used in healthcare settings that provide emergency services. Compliments DEEDS. Maintained by the NII-HIN. Improves management of critical health care information in ED settings by identifying, defining, and standardizing data elements. Facilitates exchange of critical past medical history among healthcare providers | Essential Medical Data Set (EMDS) |
| Used in Managed care organizations (MCOs). Participation is voluntary. Standardized Performance Measures used to compare performance of managed health care plans. Maintained by National Committee for Quality Assurance (NCQA). | HEDIS (Health Plan Employer Data and Information Set) |
| Health Plan Employer Data and Information Set | HEDIS |
| NCDB is the abbreviation for | National Cancer Data Base |
| Used in Acute care facilities (hospitals) for cancer registries. Participation is required for cancer registries accredited by the American College of Surgeons' Commission on Cancer, (ACoS COC). Nationwide cancer database. Assesses patterns of care and outcomes relative to national norms. Maintained by ACoS. | NCDB (National Cancer Data Base) |
| Outcome and Assessment Information Set | OASIS |
| Used in Home health agencies (HHAs). Participation is mandatory if participating in Medicare and Medicaid. Comprehensive assessment for adult home care patients. HAVEN (Home Assessment and Validation and Entry) data entry software is used. Outcomes of patient assessment, care planning and other internal performance improvement data are used for Quality Improvement/Performance Improvement. Maintained by CMS. | OASIS (Outcome and Assessment Information Set) |
| The Joint Commission Initiative | ORYX |
| Participation is required if accredited by The Joint Commission. Outcomes and other performance measurement data integrated into the accreditation process. Required to track and submit clinical performance measures to the Joint Commission. Maintained by the Joint Commission. | ORYX (The Joint Commission Initiative) |
| Uniform Ambulatory Care Data Set | UACDS |
| ACFs (Ambulatory care facilities) participation is mandatory if participating in Medicare and Medicaid. Used to improve data comparison between ambulatory and outpatient care facilities. Maintained by CMS. | UACDS (Uniform Ambulatory Care Data Set) |
| Uniform Clinical Data Set | UCDS |
| Used by Quality Improvement Organizations (QIOs). Mandatory if participating in Medicare and Medicaid. Data Elements obtained from medical records of Medicare patients that describe patient demographic characteristics, clinical history, clinical findings and therapeutic intervention. Maintained by CMS. | UCDS (Uniform Clinical Data Set) |
| Uniform Hospital Discharge Data Set | UHDDS |
| Used by Acute care facilities (hospitals). Mandatory if participating in Medicare and Medicaid. Maintained by CMS. Sponsored by National Center for Health Statistics (NCHS). Standard data collection for participants of Medicare and Medicaid programs. | UHDDS (Uniform Hospital Discharge Data Set) |
| The patient's health records contains information that has been documented by professionals whom have performed the services. ex. x-rays, scans, EKGs. | Primary Data Source |
| Data abstracted from patient records (primary source). Ex. indexes, registers, committee minutes, and incident reports. | Secondary Data Source |
| Data De-identified and often used for statistics. | Aggregated Data |
| Medical Information Bureau | MIB |
| Clearinghouse of information about people who apply for insurance. Does not receive the medical record only information to alert the underwriter of high risk conditions and the applicant should be looked at closely. It protects insurers, policyholders, and applicants from insurance fraud. | MIB (Medical Information Bureau) |
| National Practitioner Data Bank | NPDB |
| Contains information about practitioners credentials who engage in unprofessional behavior. Restricts the ability of for the physician to move to another state without disclosure of medical malpractice information and adverse action history. Healthcare Quality and Improvement Act of 1986 was implemented due to the rise in medical malpractice litigation and the need to improve the quality of medical care. | NPDB (National Practitioner Data Bank) |
| National Health Information Network | NHIN |
| Set of standards, specifications and policies that enable the secure exchange of health information over the Internet. Helping to increase patient safety, reduce medical errors, increase efficiency and effectiveness of healthcare and contain cost. | NHIN (National Health Information Network) |
| Codifies all activities in the patient record-diagnosis procedures, signs, symptoms, history, cause and etiology. Globally recognized controlled vocabulary of clinical terms used in electronic exchange. | SNOMED-CT |
| A universal standard medical vocabulary for identifying laboratory and clinical observations. | LOINC |
| Unified Medical Language System developed by the National Library of Medicine. Unites health and biomedical vocabularies and standards. Links med terminology, drug names and billing across different computer systems to help retrieve and integrate electrical biomedical information. | UMLS |
| AHIMA is the abbreviation for | American Health Information Management Association |
| Grouping of similar items that have one or more common denominators, such as diseases and procedures. They work to organize healthcare data for easy retrieval by many groups and they serve as a basis for reimbursement and case mix management. ICD-10-CM/PCS is this type of... | Classification System |
| Medical Vocabulary and Clinical Terms are also known as | Nomenclatures |
| AAPC is the abbreviation for | American Academy of Professional Coders |
| What does CCA stand for | Certified Coding Associate certification through AHIMA |
| What does CCS stand for | Certified Coding Specialist certification through AHIMA |
Created by:
WiregrassHIMT
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