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32 Cards in this Set
- Front
- Back
Accreditation organizations
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A professional organization that establishes the standards against which healthcare organizations are measured and conducts periodic assessments of the performance of individual healthcare organizations
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Aggregate data
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Data extracted from individual health records and combined to form de-identified information about groups of patients that can be compared and analyzed
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3. Allied health professionals
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A credentialed healthcare worker who is not a physician, nurse, psychologist, or pharmacist (for example, a physical therapist, dietitian, social worker, or occupational therapist)
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4. Centers for Medicare and Medicaid Service (CMS)
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The division of the Department of Health and Human Services that is responsible for developing healthcare policy in the United States and for administering the Medicare program and the federal portion of the Medicaid program; called the Health Care Financing Administration (HCFA) prior to 2001
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5. Coding specialist
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The healthcare worker responsible for assigning numeric or alphanumeric codes to diagnostic or procedural statements
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6. Confidentiality
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A legal and ethical concept that establishes the healthcare provider’s responsibility for protecting health records and other personal and private information from unauthorized use or disclosure
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7. Data
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The dates, numbers, images, symbols, letters, and words that represent basic facts and observations about people, processes, measurements, and conditions
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8. Data accessibility
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The extent to which healthcare data are obtainable
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9. Data accuracy
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The extent to which data are free of identifiable errors
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10. Data comprehensiveness
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The extent to which healthcare data are complete
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11. Data consistency
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The extent to which healthcare data are reliable
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12. Data currency
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The extent to which data are up-to-date
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13. Data definition
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the specific meaning of a healthcare-related data element
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14. Data granularity
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the level of detail at which the attributes and values of healthcare data are described
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15. Data precision
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The extent to which data have the values they are expected to have
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16. Data quality management
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A managerial process that ensures the integrity (accuracy and completeness) of an organization’s data during data collection, application, warehousing, and analysis
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17. Data relevancy
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the extent to which healthcare-related data are useful for the purpose for which they were collected
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18. Data timeliness
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same as data accuracy
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19. Diagnostic codes
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numeric or alphanumeric characters used to classify and report diseases, conditions, and injuries
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20. Electronic health record (E.H.R.)
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A computerized record of health information and associated processes
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21. Health record
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A paper- or computer-based tool for collecting and storing information about the healthcare services provided to a patient in a single healthcare facility; also called a patient record, medical record, resident record, or client record, depending on the healthcare setting
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22. Information
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Factual data that have been collected, combined, analyzed, interpreted, and/or converted into a form that can be used for a specific purpose
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23. Integrated health record format
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A system of health record organization in which all the paper forms are arranged in a strict chronological order and mixed with forms created by different departments
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24. Privacy
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The quality or state of being hidden from, or undisturbed by, the observation or activities of other persons or freedom from unauthorized intrusion; in healthcare-related contexts, the right of a patient to control disclosure of personal information
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25. Problem-oriented health record format
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A health record documentation approach in which the physician defines each clinical problem individually
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26. Procedural codes
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The numeric or alphanumeric characters used to classify and report the medical procedures and services performed for patients
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27. Quality improvement organizations (QIOs)
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An organization that performs medical peer review of Medicare and Medicaid claims, including review of validity of hospital diagnosis and procedure coding information; completeness, adequacy, and quality of care; and appropriateness of prospective payments for outlier cases and non-emergent use of the emergency room; until 2002, called peer review organization
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28. Reimbursement
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Compensation or repayment for healthcare services
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29. Source-oriented health record format
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A system of health record organization in which information is arranged according to the patient care department that provided the care
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30. Third-party payers
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An insurance company or healthcare program that reimburses healthcare providers (second party) and/or patient (first party) of the delivery of medical services
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31. Transcriptionists
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A specially trained typist who understands medical terminology and translates physicians’ verbal dictation into written reports
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32. Utilization management organization
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an organization that reviews the appropriateness of the care setting and resources used to treat a patient
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