Flashcards
Health Information Management Vocab 1
Cards in this deck (57)
- 1information relating to the physical or mental health or condition of an individual who, what, why, when, howHealth Record
- 2raw facts and figuresData
- 3data that has been turned into something meaningful.Information
- 4completely available in paper media. Some portions of it may have been created electronically, like lab results, but they are printed and filed in the paper recordPaper Health Record
- 5digital record of an individual’s health-related information that conforms to nationally recognized interoperability standards and that can be created, managed, and consulted by authorized clinicians and staff across more than one healthcare organizationElectronic Healthcare Record
EHR - 6combination of the paper record and the EHRHybrid Health Record
- 7data that has been extracted from individual health records and combined to form deidentified information about groups of patients that can be compared and analyzedAggregate Data
- 8permanent record of all patients treated at a healthcare facilityMaster Patient Index
MPI - 9links the patient’s information at the different facilitiesEnterprise Master Patient
Index EMPI - 10basic information about the patient such as their name, address, date of birth, and insurance informationDemographics
- 11results when the patient has two or more health record numbers issuedDuplicate Health Record
- 12patient is erroneously assigned another person’s health record numberOverlay
- 13patient has more than one health record number at different locations in an enterpriseOverlap
- 14requires exact matches in data elements such as the patient name, date of birth, and Social Security numberDeterministic Algorithm
- 15uses mathematical probabilities to determine the possibility that two patients are the sameProbabilistic Algorithm
- 16assigns weights to specific data elements and uses those weights to compare one record to anotherRules-based Algorithm
- 17patient is issued a unique numerical identifier for every encounter at the healthcare facilitySerial Numbering System
- 18patient is issued a health record number at the first encounter and that number is used for all subsequent encountersUnit Numbering System
- 19patient is issued a new health record number with each encounter but all of the documentation is moved from the last number to the new numberSerial-unit Numbering System
- 20The folders are filed alphabetically by the patient’s last nameAlphabetic Filing System
- 21number assigned by a healthcare facility for billing purposes that is unique to a particular episode of carePatient Account Number
- 22health records are filed by the health record numberNumeric Filing System
- 23files the records in straight numeric order based on the health record numberStraight Numeric Filing
- 24health records are filed by the last two digits, called the terminal digits, then the middle two digits, known as the secondary unitTerminal Digit Filing
- 25both alphabetic and numeric characters are used to sort health records in this systemAlphanumeric Filing
- 26all of the patient’s encounters are filed together in a single locationCentralized Unit Filing
- 27documentation that needs to be filed in the health recordloose material
- 28request for the health recordrequisition
- 29patient is discharged from the health facility, the health record is taken to the HIM department for processing. The first task is to ensure that all health records have been receivedRecord Reconciliation
- 30HIM professionals can review legibility, timeliness of documentation, use of approved abbreviations, and other documentation standardsQualitative Analysis
- 31review of the health record to determine if there are any missing reports, forms, or signaturesQuantitative Analysis
- 32in an ongoing manner while the patient is still in the healthcare facilityconcurrent review
- 33reviewed after discharge from the healthcare facilityretrospective review
- 34created when a document or signature is missingdeficiency slip
- 35health record remains incomplete for a specified number of days as defined in the medical staff rules and regulationsdelinquent record
- 36drawing a single line through the erroneous information and writing the word “error” above the mistakecorrections to Health Record
- 37additional information provided in the health recordAddendum
- 38clarification made to healthcare documentation after the original document has been signedAmendment to Health Record
- 39provides general direction about the design of the formguideline
- 40chronological set of computerized records that provides evidence of information system activityaudit trail
- 41linking of patient name, health record number, document type, and other identifying information to the scanned documentindexing
- 42unstructured narrative data that is the result of a person typing data into an information systemfree-text data
- 43computer captures the dictation and converts what is said directly into textvoice recognition technology
- 44technology that converts human language (structured or unstructured) into data that can be translated then manipulated by computer systemsnatural language processing
- 45process of extracting and analyzing large volumes of data from a database for the purpose of identifying hidden and sometimes subtle relationships or patterns and using those relationships to predict behaviorsdata mining
- 46scans the paper record and stores it digitallyDocument Management System
DMS - 47process of disclosing patient-identifiable information from the health record to another partyRelease of Information
ROI - 48the time between receipt of request and when the request is sent to requesterturnaround time
- 49assigning codes to represent diagnoses and proceduresClinical Coding
- 50process of extracting information from a document to create a brief summary of a patient’s illness, treatment, and outcomeabstracting
- 51process of extracting elements of data from a source document or database and entering them into an automated systemabstracting
- 52assigns the diagnosis and procedure codesEncoder
- 53uses the codes assigned to determine the diagnostic-related group or other groupingGrouper
- 54uses EHR data to assign the codescomputer-assisted coding
- 55database on specific diseases and procedures; for example, cancer and transplantRegistry
- 56assists physicians and other users when making decisions regarding medications, diagnoses, and such based on the information entered into the EHRClinical Decision Support
CDS - 57using certified electronic health record (EHR) technology to: •Improve quality, safety, efficiency, and reduce health disparities •Engage patients and family •Improve care coordination, and population and public health •Maintain privacy and security of patient health informationMeaningful Use