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Health Information
| Question | Answer |
|---|---|
| ABSTRACTING | Data of codes and other pertinent information(patient identification data, admission/discharge dates)utilizing computer software. |
| ACCREDITATION | Voluntary process that a health care facilities or organization undergoes to demonstrate that it has met standards beyond those required by law. |
| ACCREDITATION COUNCIL FOR GRADUATE MEDICAL EDUCATION (ACGME) | Professional organization responsible for accrediting medical training programs in the United States through a peer review process that is based on established standards and guidelines. |
| ACTIVE | Medical Staff member who delivers most hospital medical services and performs significant organizational and administrative medical staff duties. |
| AGENDA | Listing of all items of business to be discussed at committee meeting. |
| American Recovery and Reinvestment Act | Legislation that authorized an expenditure of $1.5 billion in grants for construction, renovation, and equipment, and for the acquisition of health information technology systems; Health Information Technology for Economic and Clinical Health Act (HITECH |
| American Recovery and Reinvestment Act | Act)was included in American Recovery and Reinvestment Act of 2009 and amended the Public Health Service Act to establish and Office of National Coordinator for Health Information Technology within HHS to improve health care quality, safety, and efficie. |
| ASSOCIATE | Medical staff member whose advancement to active category is being considered. |
| BIOMETRICS | An identifier that measures a borrower's unique physical characteristic or behavior and compares it to a stored digital template to authenticate the identity of the borrower, such as fingerprints, hand or face geometry, a retinal scan, or handwritten. |
| BOARD OF DIRECTORS/ GOVERNING BOARD | Membership serves without pay and is represented by professionals from the business community; has ultimate legal authority and responsibility for the hospital's operation and is responsible for the quality of care administered to patients; also called |
| GOVERNING BOARD | board of trustees, board of governors, board of directors. |
| BYLAWS | Rules that delineate medical staff responsibilities. |
| CENTERS FOR MEDICARE & MEDICAID SERVICES (CMS) | DHHS agency that provides a system of health surveillance to monitor and prevent the outbreak of diseases. |
| CHIEF RESIDENT | Position held by a physician in the final year of residency or in the year after the residency has been completed; plays a significant administrative or teaching role in guiding new residents. |
| CODE OF FEDERAL REGULATIONS (CFR) | Codification of the general and permanent rules published in the Federal Register by the executive departments and agencies of the federal government. |
| CODING | Assigning numeric and alphanumeric codes to diagnoses, procedures, and services; this function is usually performed by credentialed individuals (certified coding specialists) |
| CONTINUUM OF CARE | Arranging with outside agencies to perform certain functions, such as health information services, housekeeping, medical waste disposal, and clinical services; the purpose of contracting out these services is to improve quality while containing costs. |
| CONSULTING MEDICAL STAFF | Highly qualified practitioner who is available as a consultant when needed. |
| CURRENT PROCEDURAL TERMINOLOGY | Published annually by the American Medical Association; codes are five-digit numbers assigned to ambulatory procedures and services. |
| DEEMED STATUS | Hospitals that are accredited by approved accreditation organizations (The Joint Commission)are determined to have met or exceeded Conditions of Participation to participate in the Medicare and Medicaid programs. |
| DEEMING AUTHORITY | When and accrediting orgnization's standards have met or exceeded CMS's Conditions of Participation for Medicare certification, accredited facilities are eligible for reimbursement under Medicare and Medicaid, and CMS is less likely to conduct an on-site |
| DEEMING AUTHORITY | survey of its own. |
| DEFICIT REDUCTION ACT OF 2005 | Created the Medicaid Integrity Program (MIP, which is a fraud and abuse detection program. |
| DIGITAL SIGNATURE | Type of electronic signature that uses public key cryptography. Created using public key cryptography to authenticate a document or message. |
| DISASTER RECOVERY PLAN | Ensures an appropriate response to internal and external disasters that may affect hospital staff, patients, visitors, and the community. The plan identifies responsibilities of individuals and departments during the management of a disaster situation. |
| DO NOT RESUSCITATE (DNR) | An order documented in the patient's medical record by the physician, which instructs medical and nursing staff to not try to revive the patient if breathing or heartbeat stops. |
| ELECTRIC HEALTH RECORD (EHR) | Automated record system that contains a collection of information documented by a number of providers at different facilities regarding one patient; has the ability to link patient information created at different locations according to a unique patient |
| ELECTRIC HEALTH RECORD (EHR) | identifier;provides access to complete and accurate health problems, status, and treatment data, and contains alerts and reminders for health care providers. |
| ELECTRONIC SIGNATURE | Encompasses all technology options available that can be used to authenticate a document. Generic term that refers to the various methods an electronic document can be authenticated, including name typed at the end of an email message by the sender, |
| digitized image of a handwritten signature that is inserted or attached to an electronic document, secret or PIN to identify the sender to the recipient, unique BIOMETRICS-based identifier, or digital signature. | |
| EMERGENCY MEDICAL TREATMENT AND LABOR ACT (EMTALA) | Addressed the problem of hospitals failing to screen, treat, or appropriately transfer patients by establishing criteria for the discharge and transfer of Medicare and Medicaid patients; also called the anti-dumping statue. |
| FEDERAL REGISTER | Legal newspaper published every business day by the National Archives and Records Administration (NARA); available in paper form, on microfiche, and online. |
| FOR-PROFIT | Business in which excess income is distributed to shareholders and owners. |
| GOVERNMENT-SUPPORTED HOSPITALS | Non-for-profit, supported by local, regional, or federal taxes, and operated by local, state, or federal governments, also called public hospitals. |
| HCPCS LEVEL II (NATIONAL) CODES (HEALTH CARE PROCEDURE CODING SYSTEM) | Comprised of Level I (CPT) codes and Level II (National)codes. |
| HEALTH CARE PROXY | Legal document in which the patient chooses another person to make treatment decisions in the event the patient becomes incapable of making these decisions. |
| HEALTHCARE INTEGRITY AND PROTECTION DATA BANK (HIPDB) | Created as part of HIPAA to combat fraud and abuse in health insurance and health care delivery by alerting users to conduct a comprehensive review of a practitioner's, provider's, or supplier's past actions. |
| HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT (HIPAA) | Mandated administrative simplification regulations that governs privacy, security, and electronic transactions standards for health care information; also protects health insurance coverage for workers and their families when they change or lose their jo |
| HIPAA | Standards for privacy of individually identifiable health information.Provisions that protect the security and confidentiality of health information; also called the privacy rule. |
| HEALTH PLAN EMPLOYER DATA AND INFORMATION SET (HEDIS) | The National Committee for Quality Assurance (NCQA)"tool used by health plans to collect data about the quality of care and service they provide." |
| HILL-BURTON ACT | Provided federal grants to modernize hospitals that had become obsolete due to lack of capital investment throughout the period of the Great Depression and World War II (1929-1945); in return for federal funds, facilities agreed to provide free or reduced |
| charge medical services to persons unable to pay. | |
| HIPPOCRATES | First physician to consider medicine a science and art separate from the practice of religion. |
| HIPPOCRATIC OATH | Adopted as an expression of early medical ethics and reflected high ideals. |
| HONORARY | Retired medical staff member who is honored with emeritus status; also includes outstanding practitioners whom the medical staff wish to honor. |
| HOSPITAL ADMINISTRATION | Serves as liaison between the medical staff and governing board and is responsible for developing a strategic plan for supporting the mission and goals of the organization. |
| for developing a strategic plan for supporting the mission and goals of the organization. | |
| Hospital Departments | Provide direct patient care as well as ancillary and support services. |
| Human Genome Project | Nationally coordinated effort to characterize all human genetic material by determining the complete sequence of the DNA in the human genome;in 2000, the human genome sequencing was published. |
| Hybrid Record | Combination of paper reports and digital files. |
| Incomplete Record Processing | Includes the assembly and analysis of discharged patient records. |
| Intern | Historical term used to designate physicians in the first year of graduate medical education (GME) since 1975, the Accreditation Council for Graduate Medical Education (ACGME) has referred to individuals in their first year of GME as residents. |
| International Classification of Diseases, Ninth Revision Clinical Modification (ICD-9 CM) | Used in the United States to collect information about diseases and injuries and to classify diagnoses and procedures. ICD-9 |
| Intranet | Private network that utilizes Internet protocols and technology and allows users to immediately and simultaneously access health care information with complete security and an audit trail, regardless of where users are located. |
| Licensure | Operating a license to operate |
| Living Well | Contains the patient's instructions about the use of life-sustaining treatment. |
| Medicaid (Title 19) | Joint federal and state program that helps with medical costs for some people with low incomes and limited resources. Medicaid programs vary from state to state, but most health care costs are covered for those who qualify for both Medicare and Medicaid. |
| Medical Staff | Licensed physicians and other licensed providers as permitted by law who are granted clinical privileges. Nurses, physicians. |
| Medical Transcription | Accurate and timely transcription of dictated reports |
| Medicare (Title 18) | Health program for people 65 years of age or older, certain younger people with disabilities, and people with End-Stage-Renal Disease (ESRD), which is permanent kidney failure treated with dialysis or a transplant. |
| Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA) | Provides Medicare recipients with prescription drug savings and additional health care plan choices (other than traditional Medicare); modernizes Medicare by allowing private health plans to compete; and requires the Medicare Trustees to analyze the |
| combined fiscal status of the Medicare Trust Funds and warn Congress and the President when Medicare's general fund subsidy exceeds 45 percent. | |
| Medieval Medicine | Developed during the Middle Ages (or Dark Ages), its most significant event was the construction of hospitals to care for the sick. |
| Middle Ages | Characterized by a lack of education except among nobility and the most wealthy; also called the Dark Ages. |
| Minutes | Concise, accurate records of actions taken and decisions made during a meeting. |
| Modern Medicine | Characterized by the implementation of standards for sanitation, ventilation, hygiene, and nutrition; in addition, choosing health care as a profession became more acceptable, hospitals were reformed, and training of physicians and nurses improved. |
| National Practitioner Data Bank (NPDB) | Established by the federal Health Care Quality Improvement Act of 1986. It contains information about practitioners' credentials, including previous medical malpractice payment and adverse action history; state licensing boards, hospitals, and other |
| health care facilities access the NPDB to identify and discipline practioners who engage in unprofessional behavior. |
Created by:
jshaner