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Computer Application
Midterm review
| What does Risk Management Do? | Identifies, assesses and mitigates threats to patient safety, staff and organizational assets |
| What is Data Granulartity? | the level of detail of detail or precision of health data |
| ONYX Measures? | metrics and dashboards used within technology platforms to help meet regulatory requirements |
| What is a SNF? | Skilled Nursing Facility, provides 24/7 medical and rehabilitation services for people who are recovering from an injury, illness or surgery or have chronic conditions. |
| What is Long Term Care? | provides medical and personal care to patients who can no longer perform daily activities independently |
| What is rehabilitative care? | a comprehensive approach to restoring or improving an individuals physical, mental, and cognitive functions that have been affected by injury, illness, or surgery. |
| Who owns the EHR? | The health care provider is the legal owner of the EHR |
| Who maintains PHR when considered part of the legal health record? | the provider |
| what are conditions of participation? | formal bodies that establish standards and oversee professional certifications |
| Indexes | retrievable lists of specific data used to locate and analyze health records located within the database |
| Databases | organized, electronic collection of health care related data that is stored and managed for Easy access, analysis and updating |
| what is a query? | request for more information or clarification |
| what is validity? | data conforms to correct format, type, and range of values. data point is valid |
| what is completeness? | extent to which all required data elements for a given purpose are present |
| what is accuracy? | degree in which the data correctly reflects true, real-world value. |
| concurrent view? | process of reviewing a patients record while the patient is still recieving treatment |
| retrospective view? | refers to the analysis and review or records after the patient has been discharged |
| prospective view? | future view |
| what are data elements of MPI? | name, birthdate, gender, address, contact information |
| What is data mapping? | the process of connecting data elements from one health information system to another. Aligns and standardizes data so it can be shared. |
| What is a data dictionary and what is its purpose? | centralized dictionary that provides clear and consistent definitions for every data element within a system. it ensures data accuracy and promotes interoperability between two systems |
| what is a discharge summary? | medical document created when a patient leaves detailing the reason for the visit, key findings, and discharge instructions |
| what are the big 4's of data? | Volume, velocity, variety and veracity |
| primary data? | raw, original information collected directly from the source. exp: health record |
| secondary data? | information that has already been collected but used for a different purpose. Exp- cancer registry |
| what is considered HIPAA criminal offense? | intentional violation or patient privacy rules. exp: obtaining or disclosing PHI selling patient information |
| what is data governance | inaccurate of policies, standards, and processes that an organization uses to manage and control its data assets ensuring data accuracy, secure and usable, and compliant |
| what are federal rules of civil procedure? | disclosure, discovery and scope |
| qualitative analysis is based on what? | quality of narrative documentation rather than just the presence of data. accurate, timely, complete |
| what is severity of illness? | measures the extent of a patients condition to predict outcomes and determine level of care |
| what is comorbidity? | pre-existing medical conditions |
| what is a complication? | an unforeseen medical problem that arises after patient is admitted |
| what is present on admission? | specifies whether the medical diagnosis was present at the time of inpatient admission. used for billing |
| what is the purpose of CDI and its importance in outcome? | is the process of reviewing and improving medical records. it enhances patient care |
| what is data currency? | the degree to which data is up-to-date and reflects a patient's health status at the moment assessed. |
| what is the legal health record? | official documentation of a patients medical history, care and treatment that is maintained by the health organization or provider |
| what is data consistency? | the principal that the same data, stored in multiple places, has the same value everywhere and is uniform in format |
| What is data relevancy? | the usefulness and meaningful significance of health information for a specific purpose and decision |
| what is retention? | how long policies and procedures governing how long medical-related records must be stored |
| how are amendments handled in the EHR? | adding new, separate entry that references the original, rather than deleting or altering it. |
| what does an AHRQ quality indicator do? | uses administrative data to help healthcare provides track clinical performance and outcomes |
| what is AHRQ? | agency for healthcare research and quality. improves the quality, safety, accessibility and affordability of health care for Americans. |
| IG levels of maturity? | Risk, Aware, Aspirational, Aligned, Actualized |
| what is structed data? | information that is organized in a predefined format exp: occurs naturally |
| what is unstructured data? | information that doesn't have predefined format or fixed model exp: notes |
| what is semi-structured data? | clinical documents, device data |
| what is a clinical document? | written or electronic record detailing a patient's history |
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