Health Data Management: Principal And Ancillary Functions Of The Healthcare Record

Front 1

Data

Back 1

represent objective descriptions of processes, procedures, people and other observable things and activities.

Hint 1

Collected in form of dates, numbers, symbols, images, illustrations, texts, lists, charts and equations.

Front 2

Information

Back 2

conveys meaning, as opposed to data which represent facts.

Hint 2

results of data analyzed for a specific purpose.

Front 3

Transcriptionist

Back 3

specially trained typist who understands medical terminology.

Front 4

Financial Data

Back 4

includes patient's name, name of insured part and relationship to the patient, insured party's member ID #, name of insurance company and group policy #, employer's name and address

Front 5

Advanced Decision Support

Back 5

usefulness of EHR in making latest clinical guidelines and research findings available to physicians at a click.

Front 6

Case-mix analysis

Back 6

method of grouping patients according to a predefined set of characteristics

Front 7

Clinical practice-guidelines

Back 7

make it easier to coordinate multidisciplinary care and services.

Front 8

Core measures

Back 8

assess the quality management efforts of healthcare organizations.

Front 9

QIO

Back 9

Quality improvement organization.

Hint 9

Review appropriatenes of delivered care via patient info obtained via health records and submitted by healthcare organizations

Front 10

CMS

Back 10

Centers for Medicare and Medicaid Services

Hint 10

federal agency that administers the Medicare and Medicaid programs.

Front 11

SOW

Back 11

Statement of Work

Hint 11

Comprehensive document issued by the QIO describing their requirements over a 3 yr cycle.

Front 12

PI

Back 12

Performance improvement

Hint 12

efforts that emphasize the importance of identifying the shortcomings of processes and systems rather than individuals.

Front 13

CQI

Back 13

Continuous Quality Improvement

Hint 13

continual cycle of planning, measuring and monitoring performance & making periodic knowledge-based improvements.

Front 14

FOCUS-PDCA model

Back 14

Developed by the Hospital Corporation of America. Find a clinical process to improve; Organize a team who understand the process; Clarify team's current knowledge of process; Understand causes of undesired variation; Select improvements needed in process.

Hint 14

Applies the Plan-Do-Check-Act process, which is a cycle of trial, measurement and learning.

Front 15

RM

Back 15

Risk Management

Hint 15

Measures exercised to prevent situations that might put hospital patients, caregivers or visitors in danger.

Front 16

Accreditation

Back 16

process of granting formal approval to a healthcare organization, most often through standards developed by the Joint Commission

Front 17

Licensure

Back 17

Process of granting an organization the right to provide healthcare services, with requirements established by the state.

Front 18

Certification

Back 18

process of granting an organization the right to provide healthcare services to a specific group of individuals, often through Federal regulations met voluntarily to achieve certification.

Front 19

Biomedical research

Back 19

process of systemically investigating subjects related to the functioning of the human body.

Front 20

Corporate Negligence

Back 20

a legal doctrine established in 1965 (Darling v. Charleston Community Hospital), determining that a physician and hospital share joint liability for a patient's injury sustained as a result of substandard care.

Front 21

Medical staff bylaws

Back 21

describe rights and responsibilities of individual members and the means by which medical staff leaders govern the conduct of members.

Front 22

Credentialing

Back 22

Process involving review and validation of an individual practitioner's qualifications to practice medicine.

Front 23

NPDB

Back 23

National Practitioner Data Bank

Hint 23

collects info on medical malpractice settlements, clinical privilege actions, and medical society actions taken against licensed healthcare providers in the U.S.

Front 24

HIPDB

Back 24

Healthcare Integrity and Protection Data Bank

Hint 24

collects info on legal actions taken against licensed healthcare providers, including both civil judgements and criminal convictions

Front 25

Clinical privileges

Back 25

authorize a practitioner to provide patient services in the hospital, but only those specific services that fall within the practitioner's area of medical expertise.

Front 26

reportable incident

Back 26

an event that is considered to be inconsistent with accepted standards of care.

Front 27

Subpoena duces tecum (in context of healthcare)

Back 27

directs a hospital's representative (usually the director of HIM), to submit a specific health record or other business record to the court that holds jurisdiction over the pending proceedings.

Hint 27

May be replaced by a court order if legal counsel advises HIM that it's inappropriate to provide the information required per the subpoena

Front 28

FRCP

Back 28

Federal Rules of Civil Procedure

Front 29

NVSS

Back 29

National Vital Statistics System

Hint 29

A federal agency that operates within the CDC

Front 30

CDC

Back 30

Centers for Disease Control and Prevention

Hint 30

Group of federal agencies that oversee health promotion and disease control and prevention activities in the U.S.

Front 31

Population-based statistics

Back 31

represent estimates of the incidence of a disease as a percentage of the total population that could have been affected

Front 32

Privileged communication (concept)

Back 32

Medical practitioners are not allowed to disclose the confidential info that they learn in their capacity as professional service providers.

Front 33

Redisclosure

Back 33

Process of disclosing health record documentation originally created by a different provider