Question | Answer |
Accreditation | Voluntary compliance with a set of standards developed by an independent agent, who periodically performs audits to ensure compliance. |
Activities of daily living | refers to self-care, such as bathing, cooking, shopping, and other routines requiring thought, planning, and physical motion. |
Acute care facility | A facility that provides short-term medical treatment, usually a hospital, for patients having an acute illness or injury or recovering from surgery. |
Admission | The act of accepting a patient into care in a hospital. Also refers to the status of a patient; requires a physician’s order. |
Allied health professionals | Health care professionals who care for patients or support patient care in a variety of disciplines, including occupational therapy and physical therapy. |
Bed count | The actual number of beds that a hospital has staffed, equipped, and otherwise made available for occupancy by patients. |
Behavioral health facility | Medical facility that focuses on treatment of psychiatric conditions. |
Children’s hospital | A specialty facility that focuses on the treatment of children. |
Conditions of Participation | The terms under which a facility is eligible to receive reimbursement from Medicare. |
Continuum of care | The broad range of health care services required by a patient during an illness or for an entire lifetime. May also refer to the continuity of care provided by a health care organization. |
Deemed status | The Medicare provision that an approved accreditation is sufficient to satisfy the compliance audit element of the Conditions of Participation. |
Diagnosis | Literally, “complete knowledge”; refers to the name of the patient’s condition or illness. |
Discharge | Discharge occurs when the patient leaves the care of the facility. Also refers to the status of a patient. Discharge may be a physician order, against medical advice, or by death |
Ethics | A system of beliefs about acceptable behavior. |
Health information management (HIM) | The profession that manages the sources and uses of health information, including the collection, storage, retrieval, and reporting of health information. |
Health information technology (HIT) | The specialty in the field of health information management that focuses on the day-to-day activities of health information management that support the collection, storage, retrieval, and reporting of health information. |
Home health care | Health care services rendered in the patient’s home. Also refers to organizations that provide such services. |
Hospice | Palliative health care services rendered to the terminally ill, their families, and their friends. Also refers to organizations that provide such services. |
Hospital | An organization having permanent facilities that delivers inpatient health care services through 24-hour nursing care, an organized medical staff, and appropriate ancillary departments. |
Inpatients | An individual who is admitted to a hospital with the intention of staying overnight. |
Integrated delivery system | A health care organization that provides services through most or the entire continuum of care. |
Licensed beds | The maximum number of beds that a facility is legally permitted to have, as approved by state licensure. |
Licensure | The mandatory government approval required for performing specified activities. In health care, the state approval required for providing health care services. |
Long-term care facility | A hospital that provides services to patients over an extended period of time; an average length of stay is in excess of 30 days. Facilities are characterized by the extent to which nursing care is provided. |
Medical specialty | The focus of a physician’s practice, such as pediatrics or oncology. Specialties are represented by Boards, which certify physicians in the specialty. |
Mental health facility | Medical facility that focuses on treatment of psychiatric conditions. |
Nurse | Medical professional who has satisfied the academic, professional, and legal requirements to care for patients at state-specified levels. |
Outpatient | A patient whose health care services are intended to be delivered within 1 calendar day or, in some cases, a 24-hour period. |
Palliative care | Health care services that are intended to soothe, comfort, or reduce symptoms but are not intended to cure. |
Patient care plan | The formal directions for treatment of the patient, which involves many different individuals, including the patient. |
Physician | A medical professional who has satisfied the academic, professional, and legal requirements to diagnose and treat patients at state-specified levels and within a declared specialty. |
Primary care physician | In insurance, the physician who has been designated by the insured to deliver routine care to the insured and to evaluate the need for referral to a specialist, if applicable. Colloquial use is synonymous with “family doctor.” |
Procedure | A process that describes how to comply with a policy. Also, a medical or surgical treatment. Also refer to the processing steps in an administrative function. |
Psychiatrist | A physician who specializes in the diagnosis and treatment of patients with conditions that affect the mind. |
Referral | The act or documentation of one physician’s request for an opinion or services to another health care professional, often another physician, for a specific patient regarding specific signs, symptoms, or diagnosis. |
Rehabilitation facility | A health care facility that delivers services to patients whose activities of daily living are impaired by their illness or condition. May be inpatient, outpatient, or both. |
Resident | A person who after attending college and medical school performs professional duties under the supervision of a fully qualified physician. Also refers to a patient who resides at a Long-term care facility. |
Assessment | An evaluation. In medical decision making, the physician's evaluation of the subjective and objective evidence. Also refers to the evaluation of a patient by any clinical discipline. |
Character | A single letter, number or symbol. |
Clinical data | All of the medical data that have been recorded about the patient's stay or visit, including diagnoses and procedures. |
Computerized patient record | A digital form of the patient's paper health record. |
Data | The smallest elements or units of facts or observations. Also refers to a collection of such elements. |
Data accuracy | The quality that data are correct. |
Data collection devices | Paper forms or computer screens designed to capture data elements in a standardized format. Also refers to the physical computer hardware or other tool that facilitates the data collection process. |
Data dictionary | A list of details that describe each field in a database. |
Data validity | The quality that data reflect the known or acceptable range of values for the specific data. |
Demographic data | The kind of data used for contacting patient or to distinguish one patient from another. |
Epidemiology | The study of morbidity (disease) trends and occurrences. |
Field | A collection or series of related characters. A field may contain a word, a group of words, a number, or a code. |
File | Numerous records of different types of related data. Files can be large or small, depending on the number of records they contain. |
Financial data | Elements that describe the payer. For example, the name, address, telephone number, group number, and member number of the patient's insurance company. |
Guarantor | Responsible party for paying the bill. |
Health data | Elements related to a patient's diagnosis and procedures as well as factors that may affect the patient's condition. |
Health information | Organized data that have been collected about a patient or a group of patients. Sometimes used synonymously with the term health data. |
Health record (medical record) | Contains all of the data collected for an individual patient. |
Indicative data | Those elements that distinguish one patient from another, such as name, address, and birth date. |
Information | Data with a frame of reference i.e. processed data. |
Integrated record | A paper record in which the pages are organized sequentially, in the chronological order in which they were generated. |
Objective | In the SOAP format from medical decision making, the physician's observations and review of diagnostic tests. |
Plan of treatment | In the SOAP format for medical decision making, the diagnostic, therapeutic, or palliative measures that are taken to investigate or treat the patient's condition or disease. |
Problem-oriented record | A paper record with pages organized by diagnosis. |
Record | A collection of related fields or all of the data collected about a patient’s visit. |
Rule out | The process of systematically eliminating potential diagnoses. |
SOAP format | Subjective, Objective, Assessment, and Plan; the medical decision-making process. |
Socioeconomic data | Elements that pertain to the patient's personal life and personal habits, such as marital status, religion, and culture. |
Source-oriented record | A paper record in which pages are organized by discipline, department, and/or type of form. |
Subjective | In the SOAP format from medical decision making, the patient's description of the symptoms or other complaints. |
Symptom | The patient's report of physical or other complaints, such as dizziness, headache, and stomach pain. |
Data becomes _________ once it is organized. | Information |
A list of ______ with a frame of reference becomes information. | data |
Items, observations or raw facts are considered what? | data |
What begins with the absence of disease? | Health |
What type of controls help prevent errors? | Preventative controls |
What specialty does the Dr. treat patients who have storng reactions to pollen, insect bites, food, medication, and other irritants. | Allertist |
What specialty does the Dr. diagnose and treat patients with diseases of the heart and blood vessles. | Cardiologist |
What specialty does the Dr. administer substances that cuase loss of sensation, particularly during surger. | Anesthesiologist |
What specialty does the Dr. diagnose and treat patients with skin disorders. | Dermatologist |
What type of Dr. diagnoses and treats diseases and abnormal conditions of newborns? | Neonatologist |
The Dr. who provides care to women before, during and after pregnancy is what type of specialist. | Obstetrician |
What Dr delivers primary health care to children. | Pediatrician |
Who diagnoses and treats patients with disorders of the mind. | Psychiatrist |
The Dr. who uses x-rays and other tools to diagnose and treat a variety of diseases is called? | Radiologist |
What specialty does the Dr. diagnose and treat the reproductive system of women. | Gynecologist |
Delivers primary health care for patients of all ages. | Family Practitioner |
Diagnoses/treats diseases of the digestive system | Gastroenterologist |
Diagnoses/treats disorders of female reproductive system | Gynecologist |
Who diagnoses/treats cancer | Oncologist |
Diagnoses/treats diseases of the eye | Ophthalmologist |
Diagnoses/treats diseases of the muscles and bones | Orthopedist |
Studies changes in cells, tissue, and organs in order to diagnose diseases and/or to determine possible treatments | Pathologist |
Support the clinical staff and provide other types of services to a patient. | Non-Clinical Professional |
These patients would be cared for under a physician’s care over night as “Inpatients” | Acute Care Facilities |
Patients remain at least overnight and on an average stay less than 30 days | Acute Care Facilities |
Assigns, collects and reports codes representing clinical data | Certified Coding Specialist |
Patients are admitted and discharged on the same day also known as “Outpatient” Such as the case of going in for a procedure – Colonoscopy | Ambulatory Care Facilities |
Ambulatory Surgery – outpatient surgery, same day surgery | Ambulatory Care Facilities |
“Process of walking” | Ambulatory Care Facilities |
Inpatients are patients whose evaluation and treatments result in admission to and discharge from a facility on different days | Acute Care Facilities |
The need for more care than could be given at home. | Long-Term Care Facilities |
This type of facility provides palliative care. | Hospice Facility |
Patients remain at least overnight and on average stay longer than 30 days. | Long-Term Care Facilities |
Differences between long-term care and acute care. | Long-Term Care Facilities |
The following are examples of what?Physician’s OfficeOutpatient Office Group PracticesClinicAmbulatory SurgeryRadiology and Laboratory | Ambulatory Care Facilities |
___________ Is an example of demographic information. | Address |
What organization is responsible for workplace health and safety? | OSHA |
_______ Is an example of an acute care facility. | Hospital |
Which organization is known for setting standards in the health care industry. | JCAHO - Joint Commision on Accreditation of Healthcare Organizations. |
What accrediting body focuses on facilities that provide physical, mental, and occupational rehabilitation services. | CARF - Commission on Accreditation of Rehabilitiatiion Facilities. |
__________ is responsible for Standards that define how the health care facility should operate in terms of patient care, the clinical flow of data and documentation standards. | JCAHO |
Which organization is responsible for the Code of Ethics? | AHIMA - American Health Information Management Association |
Federally funded type of insurance plan for health care for the elderly is what? | Mediacare |
If you are studying health information managment in college, your program is accredited by___________? | CAHIIM - Commission on Accreditation for Health Informatiics and Information Management Education. |
To be eligible for reimbursement, a facility must comply with Medicare’s _____________? | Conditions of Participation |
_________ is an organization, located in Chicago, that sets standards for the health care facilities. | JCAHO |
Patient are considered “residents". | Long-Term Care Facilities |
Is an entitlement to health care benefits for persons of advanced age (over 65) or those with certain chronic illnesses | Mediacare |
Problem summary sheet is part of... | POMR |
“Nursing Home” | Long-Term Care Facilities |
___________ is an example of clinical information. | Medication |
__________ is an example of non-clinical information. | Insurance |
A Doctor's office is an example of what type of facility? | Ambulatory Care Facility |
This type of medical record has an index or historical summary of patient care management. | Problem list |
What type of medical record has everything compiled by category, ex. office visits, lab reports, radiology reports, ect. | Source-Oriented |
The type of medical record that organizes information by order of date. | Integrated Record |
units of organized knowledge i.e.… temperatures, pulse, blood pressures or name of patient, disease etc. are called ____________. | Data |
Data with a frame of reference is called ____. | Information |
Individual units of knowledge are called ________. | Data |
All of the data collected on the patient is called____________? | a health record or medical record |
All of the data must be ___________? | accurate, must have validity, must be easily stored/retrieved, organized |
____________ are examples of Key Data Categories. | Demographic Data, Socioeconomic Data, Financial Data, Clinical Data |
List examples of Demographic data. | Name and Address,Home/ Work Phone Number, Birth Date, Social Security Number |
___________ is the kind of data used for contacting patient or to distinguish one patient from another | Demographic Data |
Personal data that give clues about potential problems and assistance in planning care are considered what type of data? | Socioeconomic Data |
Examples of Socioeconomic Data are: | Marital Status, Religion, Occupation, Personal Habits, Race/Ethnicity |
Responsible party for paying the bill – guarantor is an example of | Financial Data |
Financial Data | Identifies the party responsible for paying the invoice. |
____________ are examples of Clinical Data. | Diagnosis, Temperature, Blood Pressure, Pulse, Respiration, Medications, Lab and X-ray Reports |
Data specific to the patient’s diagnosis and treatment is called? | Clinical Data |
The physician sees patient, examines, and develops an opinion about the disease or condition. This what part of SOAP | Subjective |
Physical exam, tests maybe recommended such as labs, x-rays, MRI, EKG. This is what part of a SOAP Note? | Objective |
Once the diagnosis is made, the patient may be referred to another specialty physician, such as a Cardiologist for a consult. This is what part of SOAP | Assessment |
The physician assessed the patient and make a plan for future evaluations or plan of treatment. This is what part of SOAP | Plan |
"I'm having dizzy spells and have not been taking my BP med." Belongs in what part of SOAP? | Subjective |
BP 170/110 both arems, lying down, sitting & standing; weight 202#. Belongs in what part of SOAP? | Objective |
Hypertension - Belongs in what part of SOAP? | Assessment |
Rx for Norvasc 5 mg daily; to onitor BP and return in1 week for Bp check; placed on 1200 calorie diet to lose 20#. Belongs in what part of SOAP? | Plan |
Patient calling for appointment - What kind of data is needed? | Name, Telephone number, Current patientInsurance, Reason for visit |
Patient Arrives at the Office - What kind of data is needed? | Registration Form for patient to fill out with info such as name, address, responsible person, patient history any changes etc. If new patient, create a new folder. |
Medical Assistant Taking Vitals - what data should the MA collect? | Weight, Height, Temp, Blood PressureRes/Pulse, Symptoms/How long |
60mg pseudoephedrine every 4 hours; 100 mg Tylenol as needed - is a example of what? | Plan |
Acute sinusitis with pharyngitis - is an example of what? | Assessment |
Patient complaints of headache - is an example of what? | Subjective |
Patient’s frontal sinuses sensitive to percussion; lungs clear, throat slightly inflamed - is an example of what? | Objective |
Each data is organized from date of first visit | Integrated Record |
All data is grouped together by information, such as, progress notes, lab, x-ray, surgeries, consults | Source-Oriented Record |
Advantage – Useful when the need to know when events happen in relation to each other | Integrated Record |
All of the patient’s diagnosis data are organized together, such as all diagnosis pertaining to appendicitis, or the patient’s heart problem | Problem-Oriented Record |
Advantage – Easily comparable | Source-Oriented Record |
Disadvantage – retrieval or comparison is difficult, would have to know exactly when an event or procedure happened to retrieve | Integrated Record |
Disadvantage – Complicated to file | Source-Oriented Record |
Advantage – useful when the patient has several chronic conditions that are addressed at different visits | Problem-Oriented Record |
Disadvantage – Complicated and duplication of data may be necessary so that laboratory reports related to different problems are included in all relevant sections | Problem-Oriented Record |
Integral part of a Problem-Oriented Record | Patient Summary Sheet/List |
Advantage – Versatility, all data is linked to one patient by a medical record number, solve filing and retrieval inefficiencies | Electronic Health Record |
Disadvantage – Cost | Electronic Health Record |
Same rule applies to data collected on paper or electronically. | “Garbage In, Garbage Out” |
_______ reminds the user of which data must be be collected. | A form |
The _________ ensure that complete data are collected according to the clinical guidelines of the facility and of the profession and according to regulation | forms |
All forms must be in compliance with ____________ and __________ standards (JCAHO) with signature upon whom completed | licensure, accreditation |