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RHIT STUDY GUIDE WHITE BOARD NOTES LATEST UPDATED
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Process of determining whether the medical service provided to a specific Medicare or Medicaid patient is necessary. - ANS-Utilization Review. official count of inpatients present at midnight, which is calculated each day Also included are any patients who were admitted and discharged the same day - ANS-Daily inpatient census provide consistent descriptions of medical terms for an individual's condition in the health record - ANS-Vocabulary standards When records for evidence is involved at the trial, the records custodian is called a witness by one party or other to testify as the authenticity of a record as evidence. The records custodian verifies that it contains information about the individual. - ANS- Custodian Records a graphic tool that uses standard symbols to visually display detailed information, including time and distance, of the sequential flow of work of an individual or a product as it progresses through a process - ANS-flowchart a performance improvement tool used to identify or classify the root causes of a problem or condition and to display the root causes graphically; also called the cause and effect diagram - ANS-fish bone chart Data that has been extracted from individual health records and combined to form deidentified information about groups of patients that can be compared. - ANS- Aggregated Data Mistakenly assigned another persons health record number. - ANS-Overlay When a patient has more than one health record number at different locations within an enterprise. - ANS-Overlap 2 or more medical record numbers. - ANS-Duplicate Record To control/protect access of health information and records. - ANS-Security Time between receipt of request and when the request is sent to the requester 30 days on site, 60 days off site - ANS-ROI Turnaround Time
Reviewing a record and ensuring that standards are being met. HIM professionals can review legibility, timeliness of documentation, use of approved abbreviations and other documentation standards. - ANS-Qualitative Analysis Ongoing review while patient is in facility. From admission to discharge. - ANS- Concurrent Review Review after patient has been discharged. - ANS-Retrospective Review Review that takes place prior to elective procedures and missions. - ANS-Prospective Review Organizations are the legal authority from the authorities to carry on certain activities that require permission. Before healthcare organizations can provide services, they usually must obtain licensure by government entities such as the state or county in which they are located. - ANS-Licensure Administrative and operational guidelines under which facilities are allowed to take part in the Medicare and Medicaid programs. - ANS-Conditions of Participation Industry leader in the area of healthcare provider organization accreditation. Also a non- for-profit organization accredits and certifies more than 20,000 healthcare organizations.
Principles describing how a department or organization will handle a specific situation or evaluate a specific process. They are clear simple statements of how an HIM department will conduct it's services. - ANS-Policies- Once policies are in place, procedures will define the processes by which the policies are put into action. Procedures are written documents that describe the steps involved in performing a specific function. - ANS-Procedures- Provides information on new and ongoing reviews or audits each year. - ANS-OIG Workplan- Skilled Nursing Care, Subacute Care facilities, nursing facilities nursing homes, assisted living. Care plan format is called Resident Assessment Instrument RAI- based on Minimum Data Set MDS - ANS-Long Term Care- Completed shortly after admission and discharges - ANS-Patient Assessment Instrument PAI- Commission on Accreditation of Rehabilitation Facilities - ANS-Rehab Facilities are accredited through CARF Record is organized by source. Example: All nursing notes together. - ANS-Source Oriented Health Record- System that makes unique numerical identifer number for every encounter. Example: If a patient is admitted five times, he or she will have five different health record numbers.
Free of errors - ANS-Accuracy- Accessible - ANS-Accessibility- All data elements are collected - ANS-Comprehensiveness- Ensuring all of the data is consistent and the same - ANS-Consistency- Current and up to date - ANS-Currency- All data elements must be clearly defined - ANS-Definition- Data collected must be at appropriate level of detail - ANS-Granularity- Data should be precise, in exact form. Example: height - ANS-Precision- Data is useful for the purpose it was collected - ANS-Relevancy- Documents should be entered promptly. - ANS-Timeliness- Used to track manage and store documents. - ANS-Electronic Document Management SystemEDMS- Assigning separate codes - ANS-Unbundling-. Promoting good for others or providing services that benefit others. Such as releasing a record that will help someone. - ANS-Beneficence- Core Values beliefs - ANS-AHIMA Code of Ethics- Links the patient's information at the different facilities when they go to multiple places. - ANS-Enterprise MPI- Regulation issued by CMS outlining an incentive program that adopts and successfully demonstrates meaningful use of certified EHR technology. - ANS-Meaningful Use- Provide a database of medical malpractice payments, adverse licensure actions and certain professional review actions taken by healthcare entities. - ANS-National Practitioner Data Bank- Compares organization standards against external organizations. - ANS-Benchmarking- Used as triggers to alert organizations of potential identity theft. - ANS-Red Flag Rule- 25 days or less - ANS-Average length of Stay-
A coding compliance manager reviewing tool that identifies when a user logs in and out, what he or she does, and more - ANS-Audit Trail-. Well-respected physician who can informally help physician community adapt to and ultimately adopt health IT. Is the communicator between CDI and actual physician. - ANS-Physician Advisor/Champion- Y N U W - ANS-POA INDICATIORS- Diagnosis was present at time of inpatient admission - ANS-Y- Diagnosis was not present at time of inpatient admission - ANS-N- Documentation insufficient to determine if the condition was present at the time of inpatient admission. - ANS-U- Clinically undetermined. Provider unable to clinically determine whether the condition was present at the time of inpatient admission - ANS-W- Communication tool for CDI staff to communicate with providers to obtain clinical clarification, provide a documentation alert, get documentation clarification or ask questions regarding documentation - ANS-Query-. The process an organization undertakes that will improve clinical specificity and documentation that will allow coders to assign more concise disease classification codes. - ANS-Clinical Documentation Improvement- Worksheet is a useful tool for documenting a test of change. The PDSA cycle is shorthand for testing a change by... developing a plan to test the change Plan, carrying out the test Do, observing and learning from the consequences Study, and determining what modifications should be made to the test Act. - ANS-The Plan-Do-Study-Act PDSA A challenge in extracting meaningful data from unstructured text. Clinical notes often contain terms that have more than one meaning. Example: Cold- a disease or body temperature/ Discharge- body fluid or leaving hospital. - ANS-Disambiguated Data- Patient Registration - ANS-Revenue Cycle- Front End- The documentation of the encounter in the health record, charge capture & coding. - ANS-Revenue Cycle Middle- Claims transmission, and accounts receivable. - ANS-Revenue Cycle Back End- Total work output - defective work = complete worked hours OR Completed Work / Hours worked to produce total work output - ANS-Complete Worked Hours-
Sets forth various projects including OIG audits and evaluations that are underway or planned to be addressed during the fiscal year - ANS-OIG Workplan- Major health information technology law that provides stimulus funds to the US economy in the midst of a major economic downturn. - ANS-ARRA- American Recovery and Reinvestment Act. created by ARRA- Allocates funds for implementation of a nationwide health information exchange and implementation electronic health records. - ANS-HITECH Health Information Technology for Economic and Clinical Health- Filed alphabetically by patients last name. - ANS-Alphabetic Filing System- Filed based directly by the record number in numeric order. - ANS-Straight Numeric- Filed by the last two digits terminal digits then the middle two secondary unit then first two tertiary units. - ANS-Terminal- Digit filing- The patients encounters are filed in a single location. - ANS-Centralized Unit Filing- First two letters of patients lastname followed by a uniquw numeric identifier. Ex. SA1234 - ANS-Alphanumeric Filing System- Images stored on a long roll of film, major problem is that patient encounters can be stored on multiple rolls which can make retrieval difficult. - ANS-Roll Microfilm- Microfilm is cut and inserted into 4x6 inch jackets with sleeves. - ANS-Jacket Microfilm- Copy of the jacket microfilm. Used to be sent out of the HIM Department instead of using the original Jacket Microfilm. - ANS-Microfiche- Paper-based health record system to track the location of records removed. - ANS- Outguide- Making sure that all the records have been received by the HIM department after patient has been discharged. - ANS-Record Reconciliation- Oversight of Medicare program and state governments. - ANS-CMS- Federal Agency within the US department of Health and Human Services. - Voluntary - ANS-Accreditation- Ensures patient quality, safety and improvement of clinical outcomes. - ANS-Conditions of Coverage-
Intentionally failing to comply with HIPAA provisions. - ANS-Willful Neglect- Total number of delinquent records divided by/ number of discharges. - ANS- Delinquency Rate- When healthcare providers or suppliers perform testing that is unnecessary to obtain additional money. - ANS-Abuse- Data for all Medicare claims for acute care hospital and skilled nursing facilities. Used to research topics related to types of care and DRGs, but only for Medicare patients. - ANS-Medicare Provider Analysis and Review File MEDPAR- Process of extracting information from a database then quantifying and filtering discrete, structured data. Data mining is a process used by companies to turn raw data into useful information. - ANS-Data Mining- A method used to identify the patients who have been seen or treated in the facility for the particular disease or condition of interest to the registry. - ANS-Case Finding- Critical process of bringing data into a common format that allows for collaborative research, large scale analytics, and sharing of sophisticated tools. - ANS-Data Normalization- Elected group who are responsible for successful operation of the healthcare organization. - ANS-Board of Directors- Ensure that each row in a table is unique. is can not change in value. Typically, a it is a number that is a one-up counter or a randomly generated number in large databases. A number is used because a number processes faster than an alphanumeric character. In large tables, this makes a difference. In the PATIENTS table, the PATIENT_ID is the primary key. - ANS-Primary Keys-