Last group of digits are primary for filing
Reviewing the record for consistency, completeness, and accuracy of facts
Checking patient records for correctness, presence, and authentication of all authorizations and consents
medical history is provided by
the patient or the most knowledgeable available source
chief complaint, history of present illness, past medical history, personal history, family history, and a review of systems
physical examination adds
objective data to the subjective data provided by the patient
The physical examination begins with
the physician's objective assessment of the patient's general condition
integrated progress notes
document progress notes sequentially on the same form
data entry that occurs at the point and location of service
Commission on Accreditation of Rehabilitation Facilities
an independent accrediting agency for rehabilitation facilities.
is most likely to be provided at a hospice
the accuracy of data
consistency of data
data being available within a time frame helpful to the user
data values that are just large enough to support the application of the process.
COP requires a consultation report
on patients who are not a good surgical risk
are required for elderly patients who typically take multiple medications
patient's certification period
60-day time frame for home health services
accession number 13-0001/00
"13" represents the year that the patient first entered the database
"0001" indicates that this was the first case entered that year
"00" indicates that this patient has only one known neoplasm
electronic data management system
computerized provider order entry system
National Practitioner Data Bank
With the passage of the Health Care Quality Improvement Act of 1986, the NPDB was established. Hospitals are required to query this before granting clinical privileges to physicians.
Although many patient health records may feasibly contain all of the orders listed, only the ____________ is required to document the formal release of a patient from the facility.
left against medical advice
Absence of a discharge order would indicate that the patient __________________ and this event should be thoroughly documented as well.
Conditions of Participation
CMS publishes both proposed and final rules for the _______________ for hospitals in the daily Federal Register.
Disclosure of Student Immunizations to Schools
The ___________________ provision of the final HITECH Omnibus Rule permits a covered entity to disclose proof of immunization to a school (where state law requires it prior to admitting a student) without written authorization of the parent. An agreement must still be obtained and documented, but no signature by the parent is required.
implies that data are consistent no matter how many times the same data are collected and entered into the system
implies that data are available to authorized people when and where needed
implies data that are readable
implies that all required data are present in the information system
refers specifically to the presence of all required data elements
The antepartum record should include a _____________________ on each OB patient visit with particular attention to menstrual and reproductive history.
comprehensive history and physical exam
represents a data item collected more typically in long-term care settings and required in the MDS
Principal diagnosis, procedures and data, and personal identification represent items collected on ______________ according to UHDDS requirements.
involves checking for the presence or absence of necessary reports and/or signatures
involves checking documentation consistency, such as comparing a patient's pharmacy drug profile with the medication administration record
a primary data source for health care statistics
identifies new health record numbers and the patients to whom they were assigned
identifies all patients treated by each doctor
links each patient treated in a facility with the health number under which the clinical information can be located
major source of case findings for cancer registry programs
Data Elements for Emergency Departments (DEEDS)
recommended data set for hospital-based emergency departments
Uniform Hospital Discharge Data Set (UHDDS)
required data set for acute care hospitals
Minimum Data Set (MDS)
required data set for long-term care facilities
five core measures are implemented to improve safety and quality of health care
a daily government newspaper for publishing proposed and final rules of federal agencies
denotes that data are correct values
denotes that all data items are included
denotes that the attributes and values of data should be defined at the correct level of detail
denotes that data values should be just large enough to support the application of process.
Time and means of arrival is required on
ED records only
Evidence of known advance directive is required on
inpatient records only
Problem list is required on
ambulatory records by the third visit
the primary concern in forms design
The needs of the user
"Objective symptoms observed by the physician" refers to the
"Past and current activities, such as smoking and drinking habits" refers to the
"A chronological description of patient's present condition from time of onset to present" refers to the
History of Present Illness
"review of systems" differs from "physical exam"
"subjective symptoms that the patient may have forgotten to mention or that may have seemed unimportant.”
medical staff bylaws
reflect general principles and policies of the medical staff
the rules and regulations
outline the details for implementing the general principles and policies of the medical staff, including the process and time frames for completing records, and the penalties for failure to comply.
"Adverse effects and contraindications of drugs utilized during hospitalization"
deals with issues directly linked to quality of care reviews
"quality of care through the use of pre-established criteria"
deals with issues directly linked to quality of care reviews
"Potentially compensable events"
deals with risk management
"The overall quality of documentation in the record"
points to a review aimed at evaluating the quality of documentation in the health record`
Type I recommendation
Institutions are given a _________________________ when 2% of delinquent records are due to missing history and physicals or operative reports.
RAC program (recovery audit contractors)
mandated to find and correct improper Medicare payments paid to health care providers participating in the Medicare reimbursement program
Office of Inspector General
Medicare Provider Analysis and Review
Quality Improvement Organization
The Master Patient Index (MPI)
The MPI cross-references the patient name and medical record number
the disease index is a listing in diagnostic code number order
The physician index is a listing of cases in order by physician name or number
recommended for aisles between file units when using stationary open-shelf files
Medicare's Conditions of Participation for Hospitals requires that patient health records be retained for at least __________ unless a longer period is required by state or local laws
The Food and Drug Administration require research records pertaining to cancer patients be maintained for
A quality control measure that should be established for the filing, storage, and retrieval of health records includes criteria for the
inclusion of late reports
If there is more than one patient with the identical last name, first name, and middle initial, the master patient index entries are then arranged according to the
date of birth
A 16-year-old female delivers a stillborn infant in Mercy Hospital. The clinical documentation on the stillborn infant would be filed in
the mother's record
It is recommended that all but ______________________ should be permanently retained in some format, even when the remainder of the health record is destroyed.
dates of admission, discharge, and encounters
Conditions of participation (COP)
Regulations governing providers of services to Medicare beneficiaries that require providers to develop, implement, and maintain an organization wide quality and performance improvement program.
Unless state or federal laws require longer time periods, AHIMA recommends that patient health information for minors be retained for
at least to the age of majority plus statute of limitations
database management system
an application that would be MOST effective for utilizing various related files that include clinical and financial data to generate reports such as MS-DRG case mix reports
a microform type that is the least expensive to prepare and results in the greatest storage density
the microform preferred if the records must be unitized and color-coded for filing purposes
The American College of Surgeons mandates a ___________ follow-up rate for all cancer cases to meet approval requirements as a cancer program.
the business of buying and selling information as a commodity
a large collection of clinical information systems and hospital information systems that are designed to share data without human or technical intervention
ORYX measurement requirements are intended to support
Joint Commission-accredited organizations in their quality improvement efforts
using certified electronic health record (EHR) technology to:
reduce health disparities
engage patients and family
Improve care coordination
population and public health
Maintain privacy and security of patient health information.
Continuity of care
an ideal in which health care is provided for a person in a coordinated manner and without disruption despite involvement of different practitioners in different care settings
a patient who has had a visit to any location within the previous three years
a list of illnesses, injuries, and other factors that affect the health of an individual patient, usually identifying the time of occurrence or identification and resolution
Significant medical diagnosis/condition
any nontransient problem that is significant enough to be relevant to the health of the patient going forward, as well as diagnoses that are confirmed and relevant to future care.
Significant operative and invasive procedures
any operative or invasive procedure that is significant enough to be relevant to the health of the patient going forward
Healthcare Effectiveness Data and Information Set (HEDIS)
a tool used by more than 90 % of America's health plans to measure performance on important dimensions of care and service. HEDIS consists of 71 measures across 8 domains of care.
Diagnosis-Related Group (DRG)
a statistical system of classifying any inpatient stay into groups for the purposes of payment
divides possible diagnoses into more than 20 major body systems and subdivides them into almost 500 groups for the purpose of Medicare reimbursement.
The DRG classification system
the maximum amount that most non-participating providers are allowed to charge for services to a Medicare beneficiary on an unassigned basis
a limitation on certain physician referrals
a filing system in which the records for several people or units are located in one, central location
Decentralized filing system
each department has its own records close at hand
executive information system (EIS) or
executive support system (ESS)
a type of management information system that facilitates and supports senior executive information and decision-making needs
SQL (Structured Query Language)
a tool that may be used to retrieve collected patient satisfaction data from the database to improve clinical services
HTML (Hyper Text Markup Language)
a markup language for describing web documents (web pages)
Extensible Markup Language (XML)
a markup language that defines a set of rules for encoding documents in a format which is both human-readable and machine-readable
a prerequisite in the implementation of an electronic health record, and a process that would facilitate automatic indexing
Redesigning forms to include bar codes
uses a set of standard questions that are asked to all job applicants to gather comparative data.
uses general questions from which other questions are developed over the course of the conversation
uses specific questions to determine how the interviewee responds under pressure.
Questions in this type of interview set up specific scenarios and ask the interviewee how he or she would handle the situation.
provides for fair treatment through a hearing procedure
the chief criterion for determining record inactivity
The amount of space available for storage of newer records
MDS data are reported directly to
Centers for Medicare and Medicaid Services
involves moving a document from one episode of care to a different episode of care within the same patient record
information collected for a transplant registry
patient demographic information, diagnosis codes, functional status, and histocompatibility information
A list or collection of clinical words or phrases with their meanings
medical decision making
is measured by risk of complications, number of diagnoses or management options, and the amount and complexity of data reviewed.
cutting out or off, without replacing a portion of a body part
Healthcare Cost and Utilization Project (HCUP)
consists of a set of databases that include data on inpatients whose care is paid for by third-party payers
The method of calculating errors in a coding audit that allows for benchmarking with other hospitals, and permits the reviewer to track errors by case type
statistics for your facility that include average length of stay (ALOS) and discharge data by DRG
the procedure was discontinued
antepartum care includes
routine chemical urinalysis, initial and subsequent history, and physical examination
An encoder that prompts the coder to answer a series of questions and choices based on the documentation in the medical record
International Classification on Functioning, Disability, and Health (ICF) system
a classification of health and health-related domains that describe body functions and structures, domains of activities and participation, and environmental factors that interact with all of these components
CPT Category III codes
includes codes to describe emerging technologies
The Joint Commission requires a comprehensive H & P to be completed and available
within 24 hours, or sooner if surgery is to be performed
The Joint Commission permits an interval H & P examination
when a patient is admitted within 30 days for the same condition
The Joint Commission requires that a developmental age evaluation and educational needs assessment be included in the medical history and review of systems when the patient is
a child or adolescent
a list of alternatives if several diagnoses potentially fit the patient’s clinical presentation
a unique identifier that identifies specimens in the laboratory
“Let the decision stand.”
the process of determining how much cancer is in the body and where it is located
Res Ipsa Loquitur
“The thing speaks for itself.”
applications designed to retrieve diagnostic test and treatment results from feeder systems
clinical data repository
collects, organizes, and analyzes all institutional business and clinical data that have been summarized and aggregated for that purpose
Clinical Terms Version 3
(previously known as Read Codes Version 3)
a computer based nomenclature and classification.
the devising or choosing of names for things, especially in a science or other discipline
a database of lexicographic information for use in natural language processing
Alternative Billing Codes (ABC codes)
five-digit HIPAA compliant alpha codes to describe services, remedies and/or supply items provided and/or used during patient visits.
HCPCS Level 1
CPT and is written by the American Medical Association (AMA).
HCPCS Level 2
a standardized coding system that is used primarily to identify products, supplies, and services and is written by CMS.
a catalog of terms approved for use in the description of clinical signs and problems, and for the definition of diagnoses and diseases.
three components to CPT radiology codes
professional, technical, and global components
describes the services of a physician who supervises the taking of an x-ray film and the interpretation with report of the results
describes the services of the person who uses the equipment, the film, and other supplies
describes the combination of both professional and technical components
radiologist only the professional component of the procedure
used for maintenance therapy in congestive heart failure, atrial fibrillation, atrial flutter, and paroxysmal atrial tachycardia
an anti-inflammatory drug
used to initiate or improve uterine contractions at term
used to manage psychotic disorders
Unified Medical Language System (UMLS)
a project sponsored by the National Library of Medicine
A cancer program is surveyed for approval by
the Commission on Cancer of the American College of Surgeons
review patient record and enter the required elements into a database
If no bilateral code is provided and the condition is bilateral
assign separate codes for both the left and right side
reference date for a cancer registry
the date when data collection began
The most common type of registry in hospitals of all sizes
the database/registry you will utilize most often
The National Practitioner Data Bank (NPDB)
One of the major functions of the cancer registry
to ensure that patients receive regular and continued observation and management
Patient follow-up in cancer registry should be continued
for the life of the patient
the primary concern when designing systems
The needs of the end user
Histocompatibility information is collected and maintained in the
organ transplant registry
When a provider, knowingly or unknowingly, uses practices that are inconsistent with accepted medical practice and that directly or indirectly result in unnecessary costs to the Medicare program, this is called
DRG system that classifies the non-Medicare population, such as HIV patients, neonates, and pediatric patients
ANSI ASC X12N 837
electronic format for health care claims transactions
HCPCS/CPT codes that appear in the hospital's chargemaster and will be included automatically on the patient's bill
CMS adjusts the Medicare Severity DRGs and the reimbursement rates every fiscal year beginning
sent to patients (beneficiaries) as their EOB
Medicare Summary Notice (MSN)
Medicare summary notice
a statement sent to the patient to show how much the provider billed, how much Medicare reimbursed the provider, and what the patient must pay the provider
Accounts Receivable (A/R)
cases that have not yet been paid
the patient is financially liable for charges in excess of the Medicare Fee Schedule, up to a limit
a uniform system of identifying procedures, services, or supplies
IPPS Transfer rule
hospitals are paid a graduated per diem rate for each day of the patient’s stay, not to exceed the prospective payment DRG rate
financial protections to ensure that certain types of facilities recoup all of their losses due to the differences in their APC payments and the pre-APC payments.
a narrative name of the services provided
15% above Medicare's approved payment amount for doctors who do NOT accept assignment
When the third-party payer refuses to grant payment to the provider
a health care program for active members of the military and other qualified family members
the claim form used by hospitals
the claim form used by physicians and other noninstitutional providers and suppliers
the claim form used by ambulance services
Rehabilitation hospitals are reimbursed under the
Inpatient Rehabilitation Prospective Payment System (IRF PPS)
Long-term care hospitals are reimbursed under the
Long-Term Care Hospital Prospective Payment System (LTCH PPS)
Skilled nursing facilities are reimbursed under the
Skilled Nursing Facility Prospective Payment System (SNF PPS)
Cancer hospitals can apply for and receive waivers from ______________________________ and are therefore excluded from the inpatient prospective payment system (MS-DRGs).
the Centers for Medicare and Medicaid Services (CMS)
the 72-hour rule
This rule requires that outpatient preadmission services that are provided by a hospital up to three calendar days prior to a patient's inpatient admission be covered by the IPPS MS-DRG payment for diagnostic services and therapeutic (or nondiagnostic) services whereby the inpatient principal diagnosis code (ICD-10-CM) exactly matches the code used for preadmission services.
Advance Beneficiary Notice (ABN)
a document signed by the patient indicating whether he/she wants to receive services that Medicare probably will not pay for
A lump-sum payment distributed among the physicians who performed the procedure or interpreted its results and the health care facility that provided equipment, supplies, and technical support
the service or procedure is reasonable and necessary for the diagnosis or treatment of illness or injury consistent with generally accepted standards of care
Never events or Sentinel events
errors in medical care that are clearly identifiable, preventable, and serious in their consequences for patients
prospective payment system
based on resource utilization groups (RUGs) is used for reimbursement to skilled nursing facilities for patients with Medicare
a joint federal and state program that provides health care coverage to low-income populations and certain aged and disabled individuals
a method that attributes a dollar figure to every input required to provide a service
explanation of benefits
a statement sent by a health insurance company to covered individuals explaining what medical treatments and/or services were paid for on their behalf
3 main components of a healthcare organization
- The governance
- The management
- The employed staff
Resource Utilization Groups (RUG)
MDS assessment forms are completed for all residents in certified nursing homes, regardless of source of payment for the individual resident.
Communities of Practice (CoP)
groups of people who share a concern or a passion for something they do and learn how to do it better as they interact regularly
an ordered test or group of tests on a particular specimen which has been formally received by a lab or other health care service and has received an accession number.
To input the demographics for a particular patient’s analysis into an information system; to log or document receiving a specimen in the lab.
Coding audit methods
- Select charts randomly
- Don’t review your own charts
- Use the same rules as the auditors
- Keep coding audits results professional and educational
- Work at correcting errors
CPT codes Category I
Procedures that are consistent with contemporary medical practice and are widely performed.
CPT codes Category II
Supplementary tracking codes that can be used for performance measures
CPT codes Category III
Temporary codes for emerging technology, services and procedures
the act of granting approval to a healthcare organization
a states act of granting a healthcare organization or an individual healthcare practitioner permission to provide services of a defined scope in a limited geographical are
grants approval for a healthcare organization to provide services to a specific group of beneficiaries
the process of meeting a prescribed set of standards or regulations to maintain active accreditation, licensure, or certification status
Quality Improvement Organizations (QIO)
review patient records to ensure that the care provided by practitioners meets the federal standards for medical necessity, level of care, and quality of care.
Measures of success data
data specifically developed for the organizations compliance with Joint Commission standards
Quality Indicator Survey
a two-staged survey process designed to produce a standardized resident-centered, outcome-oriented quality review
an organization-wide framework for managing information throughout its lifecycle and supporting the organization’s strategy, operations, and regulatory, legal and environmental requirements
The Triple Aim
Care, health, and cost
The person who actually uses a particular product
Under ASC PPSs, bilateral procedures are reimbursed at
150% of the payment rate for their group
LCD (Local Coverage Determinations)
is published by the Medicare Administrative Contractors (MACs) to describe when and under what circumstances Medicare will cover a service.
A computer software program that assigns appropriate MS-DRGs according to the information provided for each episode of care
A three-digit code that describes a classification of a product or service provided to a patient
method that issues lump-sum payments to providers to compensate them for all the health care services delivered to a patient for a specific illness and/or over a specific period of time.
Medicare Part B
offers voluntary, supplemental medical insurance to help pay for physician's services, outpatient hospital services, medical services, and medical-surgical supplies not covered by the hospitalization plan
State Medicaid programs are required to offer medical assistance for individuals with
qualified financial need.
electronic data interchange (EDI)
computer-to-computer transfer of data between providers and third-party payers in a data format agreed upon by both parties
prospective payment system used to reimburse hospitals for Medicare hospital outpatients
In calculating the fee for a physician's reimbursement, the three relative value units are each multiplied by the
geographic practice cost indices
The three relative value units are
physician work, practice expense, and malpractice expense
Payment Status Indicator (PSI) "T" means
if a patient has more than one CPT code with this PSI, the procedure with the highest weight will be paid at 100% and all others will be reduced or discounted and paid at 50%.
the gathering of charge documents from all departments within the facility that have provided services to patients.
The purpose is to make certain that all charges are coded and entered into the billing system.
Modifying the natural anatomic structure of a body part without affecting the function of the body part
Altering the route of passage of the contents of a tubular body part
Taking out or off a device from a body part and putting back an identical or similar device in or on the same body part without cutting or puncturing the skin or mucous membrane
Stopping, or attempting to stop, post-procedural bleeding
Making a new genital structure that does not physically take the place of a body part
Physical eradication of all or a portion of a body part by the direct use of energy, force, or a destructive agent
Cutting off all or part of the upper or lower extremities
Expanding an orifice or the lumen of a tubular body part
Cutting into a body part without draining fluids and/or gases from the body part in order to separate or transect a body part
Taking out/letting out fluids and/or gases from a body part
Cutting out or off, without replacement, a portion of a body part
Taking or cutting out solid matter from a body part
Pulling or stripping out or off all or a portion of a body part by the use of force
Breaking solid matter in a body part into pieces
Joining together portions of an articular body part rendering the articular body part immobile
Putting in a non-biological device that monitors, assists, performs, or prevents a physiological function but does not physically take the place of a body part
Visually and/or manually exploring a body part
Locating the route of passage of electrical impulses and/or locating functional areas in a body part
Completely closing an orifice or the lumen of a tubular body part
Putting back in or on all or a portion of a separated body part to its normal location or other suitable location
Freeing a body part from an abnormal physical constraint by cutting or by use of force
Taking out or off a device from a body part
Restoring, to the extent possible, a body part to its normal anatomic structure and function
Putting in or on biological or synthetic material that physically takes the place and/or function of all or a portion of a body part
Moving all or a portion of a body part to its normal location or other suitable location
Cutting out or off, without replacement, all of a body part
Putting in or on biologic or synthetic material that physically reinforces and/or augments the function of a portion of a body part
Partially closing an orifice or the lumen of a tubular body part
Correcting, to the extent possible, a malfunctioning or displaced device
Moving, without taking out, all or a portion of a body part to another location to take over the function of all or a portion of a body part
Putting in or on all or a portion of a living body part taken from another individual or animal to physically take the place and/or function of all or a portion of a similar body part
Cutting through the skin or mucous membrane and any other body layers necessary to expose the site of the procedure
Entry, by puncture or minor incision, of instrumentation through the skin or mucous membrane and any other body layers necessary to reach the site of procedure
Percutaneous endoscopic approach
Entry, by puncture or minor incision, of instrumentation through the skin or mucous membrane and any other body layers necessary to reach and visualize the site of the procedure
Via Natural or Artificial Opening approach
Entry of instrumentation through a natural or artificial external opening to reach the site of the procedure
Via Natural or Artificial Opening Endoscopic approach
Entry of instrumentation through a natural or artificial external opening to reach and visualize the site of the procedure
Via Natural or Artificial Opening with Percutaneous Endoscopic Assistance approach
Entry of instrumentation through a natural or artificial opening and entry, by puncture or minor incision, of instrumentation through the skin or mucous membrane and any other body layers necessary to aid in the performance of the procedure
procedures performed directly on the skin or mucous membrane and procedures performed indirectly by the application of external force through the skin or mucous membrane
Root Operations That Take Out Solids, Fluids, Gases from a Body Part
Root Operations Involving Cutting or Separation Only
Root Operations That Put in or Put Back or Move Some or All of a Body Part
can be either spread through autoinoculation or caused by Streptococcus pyogenes
a condition that involves the fifth cranial nerve, also known as "tic douloureux," causes intense pain in the eye and forehead; lower lip, the section of the cheek closest to the ear and the outer segment of the tongue; or the upper lip, nose, and cheek
The most common type of vaginitis
both yeast and protozoan
Cancer derived from epithelial tissue is classified as
Carpal tunnel syndrome is caused by
entrapment of the medial nerve
laparoscopic gastric banding
The least invasive restrictive gastric surgery
A disease of the inner ear with fluid disruption in the semicircular canal that causes vertigo
both labyrinthitis and Meniere's disease
drug commonly used to treat bipolar mood swings
"pill-rolling" tremor of the hand is a characteristic symptom
The first stage of alcoholic liver disease is
Increased glucose metabolism is an effect of
the presence of Reed-Sternberg cells
is indicative of Hodgkin's disease
Obesity, cigarette smoking, and age are all conditions which predispose risk associated with
Chronic bronchitis, emphysema, and smoking fall under the category of
Portal hypertension can contribute to
ascites, dilation of the blood vessels lining the intestinal tract and esophageal varices
Removal FB left cornea (root operation)
Mitral valve annuloplasty using ring, open (root operation)
Amputation first left toe (root operation)
Application of skin graft to the nose status post excision malignant neoplasm
In the Medical Surgical Section, the second character position represents
In the Medical Surgical Section, the third character position represents
Uterine dilation and curettage (root operation)
In the Medical Surgical Section, the fourth character position represents?
Gastric lap band for treatment of morbid obesity (root operation)
a procedure used to help prevent miscarriage
What is the optimal level of total cholesterol in the blood for adults?
< 200 mg/dL
A common cardiac glycoside medication that increases the force of the cardiac contraction without increasing the oxygen consumption, thereby increasing the cardiac output is typically given to patients with heart failure
a T cell that influences or controls the differentiation or activity of other cells of the immune system
cytotoxic T cells
A cytotoxic T cell is a T lymphocyte (a type of white blood cell) that kills cancer cells, cells that are infected (particularly with viruses), or cells that are damaged in other ways
cells that produce antibodies
Alpha cells (more commonly alpha-cells or α-cells) are endocrine cellsin the pancreatic islets of the pancreas. They make up to 20% of the human islet cells synthesizing and secreting the peptide hormone glucagon, which elevates the glucose levels in the blood.
helper B cells
B cells, also known as B lymphocytes, are a type of white blood cell of the lymphocyte subtype. They function in the humoral immunity component of the adaptive immune system by secreting antibodies. Additionally, B cells present antigen (they are also classified as professional antigen-presenting cells (APCs)) and secrete cytokines.
a long-lived lymphocyte capable of responding to a particular antigen on its reintroduction, long after the exposure that prompted its production
a cell filled with basophil granules, found in numbers in connective tissue and releasing histamine and other substances during inflammatory and allergic reactions
a chronic, systemic disease whose initial infection is in the lungs
the body’s immune system reverses itself and attacks the organs and tissues
5 layers of the epidermis
A hematology laboratory test that evaluates the oxygen-carrying capacity of blood
A tube that conveys sperm from the seminal vesicle to the urethra
Increasing peristalsis of the intestines, increasing salivation, and a slowing heart rate are examples of
parasympathetic nervous system
Sympathetic nervous system
A part of the nervous system that serves to accelerate the heart rate, constrict blood vessels, and raise blood pressure
autonomic nervous system
the part of the nervous system responsible for control of the bodily functions not consciously directed, such as breathing, the heartbeat, and digestive processes
prothrombin time (PT) test evaluates
coagulation of the blood
is an autoimmune disease
SARS (severe acute respiratory syndrome)
Methicillin-resistant Staphylococcus aureus (MRSA)
is caused by a type of staph bacteria that's become resistant to many of the antibiotics used to treat ordinary staph infections
Novel H1N1 influenza
A virus responsible for a flu pandemic in 2009 that was originally referred to as "swine flu" because many of the genes in this new virus were very similar to influenza viruses that normally occur in pigs in North America
a severe, chronic, two-phased, bacterial respiratory infection that has become increasingly difficult to treat because many antibiotics are no longer effective against it
Coronary artery bypass grafting (CABG)
improves the coronary blood flow by building an alternate route for the blood to bypass the blockage by inserting a portion of another blood vessel, typically the saphenous vein
Percutaneous transluminal coronary angioplasty (PTCA)
a minimally invasive procedure to open up blocked coronary arteries, allowing blood to circulate unobstructed to the heart muscle
Carotid endarterectomy (CEA)
a surgical procedure used to reduce the risk of stroke, by correcting stenosis (narrowing) in the common carotid artery or internal carotid artery
the removal of material on the inside (end(o)-) of an artery
The organism transmitted by a mosquito bite that causes malaria
Softening of the bone in children
carcinoembryonic antigen (CEA) test
measures the amount of this protein that may appear in the blood of some people who have certain kinds of cancers
Acute myocardial infarction (AMI)
Rocky Mountain spotted fever
The most common rickettsial disease in the United States
The interaction of two drugs working together to where each simultaneously helps the other achieve an effect that neither could produce alone
the usual treatment for Helicobacter pylori
Gardasil is a quadrivalent vaccine. What is the definition of quadrivalent?
It prevents infection from the four most prevalent types of HPV that cause cervical cancer.
A treatment for sensorineural hearing loss is
A distinguishing characteristic of a toxic goiter is
liver function test
Rheumatoid arthritis typically affects
the knees and small joints of the hands and feet
The etiology of aplastic anemia is
bone marrow failure
the organ that has endocrine and exocrine functions
the QRS wave
the electronic stimulation of the ventricles
atrial depolarization, which results in atrial contraction
the period that extends from the beginning of the P wave (the onset of atrial depolarization) until the beginning of the QRS complex (the onset of ventriculardepolarization)
a measure of the time between the start of the Q wave and the end of the T wave in the heart's electrical cycle
connects the QRS complex and the T wave
represents the repolarization (or recovery) of the ventricles
A common vitamin taken by pregnant women to substantially reduce the occurrence of neural tube defects, such as spina bifida, in a developing fetus
A sweat test was done on a patient with the following symptoms: frequent respiratory infections, chronic cough, and foul-smelling bloody stools. What diseases is probably suspected?
a hereditary disease of the cerebral cortex that includes progressive muscle spasticity and mental impairment leading to dementia
aralysis of the facial nerve, causing muscular weakness in one side of the face
Amyotrophic lateral sclerosis (ALS)
sometimes called Lou Gehrig's disease, is a rapidly progressive, invariably fatal neurological disease that attacks the nerve cells (neurons) responsible for controlling voluntary muscles
Guillain–Barré syndrome (GBS)
a rapid-onset muscle weakness caused by the immune system damaging the peripheral nervous system
a deficiency in the production of red blood cells through a lack of vitamin B12
Autoimmune hemolytic anemia
occurs when antibodies directed against the person's own red blood cells (RBCs) cause them to burst (lyse), leading to insufficient plasma concentration.
deficiency of all types of blood cells caused by failure of bone marrow development
The state of balance or normality that the human body continuously tries to attain
Diastole occurs when
the ventricles fill
systole occurs when
the heart contracts and pumps out blood to the rest of the body
the ability of the blood to clot is severely reduced
any of a group of hereditary hemolytic diseases caused by faulty hemoglobin synthesis
Too few healthy red blood cells due to too little iron in the body.
superior and inferior rectus
the set of muscles that controls the movement of the eye up and down
a lethal arrhythmia
What term would be applied to a comparison of the number of female
patients to the number of male
patients who were discharged from MS-DRG YYY?
Suppose that there are six males in a class of twenty students. What
term could be used to
describe the comparison?
What descriptive statistics is calculated by applying this equation: (x/y) x 10n?
In May, 270 women were admitted to the Obstetrics service. Of these,
263 women delivered; 33
deliveries were by C-section. What is the denominator for calculating the C-section rate?
Suppose that you want to display the number of deaths due to breast
cancer for the years 1990
through 1999. What graphic technique would you choose?
Suppose that you want to display the average length of stay by gender
and service for the month of
August. What graphic technique would you choose?
If you are interested in displaying the parts of a whole in graphic
form, what graphic technique
would you use?
In a frequency distribution, the lowest value is 5 and the highest value is 20. What is the range?
I just realized that we may be misleading administration with the
data we provided them.
Which of the following might we have done?
Failed to adjust the baseline
I work for AHRQ. I have to choose the next project for AHRQ. Which of
following would I choose?
A study to determine how the EHR improves patient safety and quality of care
Which rate describes the number of new cases of an illness for a specific time period?
Which term is used to describe the number of inpatients present at
the census- taking time each
day plus the number of inpatients who were both admitted and discharged after the census-taking time
the previous day?
Daily inpatient census
Which unit of measure is used to indicate the services received by
one inpatient in a 24-hour
Inpatient service day
Which rate is used to compare the number of inpatient deaths to the
total number of inpatient
deaths and discharges?
Gross hospital death rate
Suppose a patient who underwent orthopedic surgery acquired
Klebsiella pneumonia while
hospitalized. How could this illness be described?
As a postoperative infection
As a hospital-acquired infection
As a community acquired infection
Which term is used to describe the number of calendar days that a patient is hospitalized?
Length of stay
What rate is used to indicate the percentage of the hospital’s beds
occupied by inpatients for a
given time period?
Percentage of occupancy
Inpatient bed occupancy rate
Which rate compares the number of autopsies performed on hospital
inpatients to the total
number of inpatient deaths for the same period of time?
Gross autopsy rate
Suppose that five patients stayed in the hospital for a total of 27
days. Which term would be used
to describe the result of the calculation 27 ÷ 5?
Average length of stay
The probability of death among diagnosed cases of a specific disease
case fatality rate
Data elements that are considered protected under the HIPAA Privacy Rule
Patient telephone number
Medical record number
Agency for Healthcare Research and Quality
insulin-dependent diabetes mellitus (AKA: diabetes 1 and juvenile diabetes)
bone density scan
All Patients Refined Diagnosis Related Groups
All Patients Refined Diagnosis Related Groups (APR DRG)
A classification system that classiﬁes patients according to their reason of admission, severity of illness and risk of modality - The patient characteristics used in the definition of the DRGs are limited to.
POA indicator is assigned to
principal and secondary diagnoses
Prospective Payment System
Inpatient Rehabilitation Facility Prospective Payment System
Inpatient Rehabilitation Facility Patient Assessment Instrument
Electronic Funds Transfer
National Coverage Determinations
Home Assessment Validation Entry was designed for the stand-alone home health agency as a data entry tool to encode and edit the OASIS data.
Resource-based relative value scale
Resource-based relative value scale (RBRVS)
a schema used to determine how much money medical providers should be paid. It is partially used by Medicare in the United States and by nearly all health maintenance organizations (HMOs).
an autoimmune disease, a disorder in which the immune system turns against the body's own tissues, the immune system attacks the thyroid
antiglomerular basement antibody disease, or anti-GBM disease) is a rare autoimmune disease in which antibodies attack the basement membrane in lungs and kidneys, leading to bleeding from the lungs and kidney failure
autoimmune diseases affects tissues of the nervous system. A weakness and rapid fatigue of muscles under voluntary control
Most carbon dioxide is carried in the
red blood cells
the average timeframe in which all patients with new, previously untreated TB must have daily antibiotic therapy
The process of cancer development, from exposure through the cellular changes of hyperplasia to neoplasia
a lethal arrhythmia
guaiac smear test
Fecal occult blood test
prostatic-specific antigen test
is a protein produced by cells of the prostate gland, measures the level of PSA in a man's blood.
The hypothalamus, thalamus, and pituitary gland are all parts of the
A serum potassium level of 2.8 would indicate
A disorder in which the adrenal glands don't produce enough hormones. Specifically, the adrenal glands produce insufficient amounts of the hormone cortisol and sometimes aldosterone, too.
deficiency of potassium in the bloodstream
endocrine gland secretes melatonin, which controls the circadian rhythm of an individual
beta cells of the pancreas, they make insulin and amylin
adrenal medulla secretes
Cortisol, Aldosterone, and Androgenic steroids (androgen hormones)
alpha cells of the pancreas
secrete pancreatic polypeptide
The progress of a disease
the cause a disease or condition
Most of the digestion of food and absorption of nutrients occur in the
Sex-linked genetic diseases
involve a defect on a chromosome
hereditary hemochromatosis (HH)
is a genetic disease that alters the body's ability to regulate iron absorption
An inherited life-threatening disorder that damages the lungs and digestive system.
A rare, inherited disorder that destroys nerve cells in the brain and spinal cord. A fatty substance in the brain destroys nerve cells.
A birth defect that causes an amino acid called phenylalanine to build up in the body.
Newborns are screened for PKU.
Untreated PKU can lead to brain damage, mental retardation, behavioral symptoms, or seizures.
Treatment includes a strict diet with limited protein.
Decubitus ulcer stage 1
sores are not open wounds. The skin may be painful, but it has no breaks or tears.
Decubitus ulcer stage 2
the skin breaks open, wears away, or forms an ulcer, which is usually tender and painful. The sore expands into deeper layers of the skin. It can look like a scrape (abrasion), blister, or a shallow crater in the skin.
Decubitus ulcer stage 3
the sore gets worse and extends into the tissue beneath the skin, forming a small crater. Fat may show in the sore, but not muscle, tendon, or bone.
Decubitus ulcer stage 4
the pressure sore is very deep, reaching into muscle and bone and causing extensive damage. Damage to deeper tissues, tendons, and joints may occur.
the upper respiratory tract
The nose, mouth, sinuses, pharynx, and larynx
the lower respiratory tract
the windpipe (trachea) and within the lungs, the bronchi, bronchioles, and alveoli.
upper gastrointestinal tract
the esophagus, stomach and duodenum
lower gastrointestinal tract
the anus, rectum, colon, and cecum
von willebrand disease
A bleeding disorder caused by low levels of clotting protein in the blood
Inflammation of bone caused by infection, generally in the legs, arm, or spine
a benign tumor formed from glandular structures in epithelial tissue
a benign, tumor-like growth made up mostly of fibrous or connective tissue
A common pigmented skin lesion, usually developing during adulthood (mole)
A fatty lump most often situated between the skin and underlying muscle layer
a malignant tumor formed from glandular structures in epithelial tissue
a malignancy of fat cells
A type of bone cancer that begins in the cells that form bones
Original site or point of origin
Site or sites where malignancy has spread (metastases)
in original place
CANCER DEVELOPMENT STAGES
NORMAL CELLS -- HYPERPLASIA -- DYSPLASIA CANCER IN SITU -- INVASIVE CANCER
when the neoplasm behavior cannot be determined pathologically
when the behavior is not stated
When coding surgical removal of a neoplasm followed by adjunct chemotherapy or radiation treatment during the same episode of care, the code for the neoplasm should be assigned as
principal or first-listed diagnosis
Thickened, white patches inside the mouth
an increase in the total number of WBCs due to any cause
an increase in the number of lymphocytes in the blood
a form of small leukocyte (white blood cell) with a single round nucleus, occurring especially in the lymphatic system that are of fundamental importance in the immune system
help fight infection by ingesting microorganisms and releasing enzymes that kill the microorganisms
is an abnormally low level of neutrophils
a large phagocytic white blood cell that fights off bacteria, viruses and fungi
a type of white blood cell that play an important role in the body's response to allergic reactions, asthma, and infection with parasites
A cancer of plasma cells. The disease can damage the bones, immune system, kidneys, and red blood cell count.
Plasma cell neoplasms
diseases in which there are too many plasma cells, or myeloma cells, that are unable to do their usual work in the bone marrow
According to CPT guidelines, when a patient is admitted to the hospital on the same day as an office visit, the office visit is
performed to prevent recurrence of pneumothorax or recurrent pleural effusion
the removal of the outer layer or cortex from a structure, especially the lung, brain, or other organ
ingrowth or introversion of the eyelashes
a soft tube that is placed during surgery. This tube has a curl at both ends designed to prevent the stent from moving down into the bladder or up into the kidney
medical procedure by which an abnormally fast heart rate (tachycardia) or cardiac arrhythmia is converted to a normal rhythm using electricity or drugs
determination of the number and condition of spermatozoa in mucus aspirated from the canal of the cervix uteri within 2 hours after coitus
a protrusion of the meninges through a gap in the spine due to a congenital defect
the surgical removal of one or both adrenal glands
interventional radiologists use image guidance to make a tunnel through the liver to connect the portal vein (the vein that carries blood from the digestive organs to the liver) to one of the hepatic veins (three veins that carry blood away from the liver back to the heart).
A legally-effective, voluntary agreement that is given by a prospective research participant following comprehension and consideration of all relevant information pertinent to the decision to participate in a study.
Belmont principle of justice
- Respect for persons
The principle of respect
1. Individuals should be treated as autonomous agents
2. Persons with diminished autonomy are entitled to additional protections
An individual capable of deliberation about personal goals and of acting under the direction of such deliberation
influencing an individual's decision about whether or not to do something by using explicit or implied threats (loss of good standing in a job, poor grades, etc.).
An offer of an excessive, unwarranted, inappropriate, or improper reward or other overture in order to obtain compliance
- Do no harm
- Maximize possible benefits and minimize possible harms
a concept in research ethics which states that researchers should have the welfare of the research participant as a goal of any clinical trial or other research study. The antonym of this term, maleficence, describes a practice which opposes the welfare of any research participant.
An individual with restricted capability of deliberation about personal goals and of limited ability to act under the direction of their deliberations.
Institutional Review Board
consist of 5 or more members with varying expertise and diversity that are responsible for reviewing and approving human subjects research activities on behalf of institutions.
often the first step in database design and object-oriented programming as the designers first create a conceptual modelof how data items relate to each other.
a set of information describing the contents, format, and structure of a database and the relationship between its elements, used to control access to and manipulation of the database
database management system
database management system (DBMS)
a computer software application that interacts with the user, other applications, and the database itself to capture and analyze data (it is the interface engine that will be needed to manage communication between systems)
documented agreements on representation, format, and definition for common data
industry standard data model
industry standard data model (ISDM)
A data model that is widely applied in some industry, and shared amongst competitors to some degree. They are often defined by standards bodies, database vendors or operating system vendors
decision support system (DSS)
a computer program application that analyzes business data and presents it so that users can make business decisions more easily
clinical decision support system (CDSS)
a health information technology system that is designed to provide physicians and other health professionals with clinical decision support (CDS), that is, assistance with clinical decision-making tasks
knowledge-based system (KBS)
a computer program that reasons and uses a knowledge base to solve complex problems
financial information system
Atype of business software used to input, accumulate, and analyze financial and accounting data. It produces reports such as accounting reports, cash flow statements, and financial statements
One of the ways that an EHR is distinguished from a clinical data repository is that the EHR
has clinical decision support capabilities
a field (or collection of fields) in one table that uniquely identifies a row of another table
The foreign key is defined in a second table, but it refers to the _____________________ in the first table.
request for information (RFI)
a standard business process whose purpose is to collect written information about the capabilities of various suppliers. Normally it follows a format that can be used for comparative purposes
request for information
a systematic process of evaluating the potential risks that may be involved in a projected activity or undertaking
request for proposal
a solicitation, often made through a bidding process, by an agency or company interested in procurement of a commodity, service or valuable asset, to potential suppliers to submit business proposals
request for proposal
an assessment of the practicality of a proposed plan or method
a formal document designed to guide the control and execution of a project
an organization's process of defining its strategy, or direction, and making decisions on allocating its resources to pursue this strategy
a declaration of an organization's objectives, ideally based on economic foresight, intended to guide its internal decision-making
front-end speech recognition
that the original dictator's speech is turned into text
back-end speech recognition
a speech recognition system where the staff dictates and then the editing of the dictation is done by editors
a subfield of speech recognition that deals with the identification of keywords in utterances
A common language used in data definition and data manipulation
Unified Modeling language
Unified Modeling language (UML)
A standardized modeling language enabling developers to specify, visualize, construct and document artifacts of a software system.
a set of data that describes and gives information about other data
A function is found in an ambulatory EHR but not in an acute care EHR
electronic medication administration record
electronic medication administration record (eMAR)
Automatically track medications from order to administration using assistive technologies
using 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 information
This Medicare program requires the use of a certified electronic health record
a type of network topology that uses two or more other network topologies, including bus topology, mesh topology, ring topology, star topology, and tree topology
formal standards and policies comprised of rules, procedures and formats that define communication between two or more devices over a network
the placement of the various components of a network, including device location and cable installation, while logical topology illustrates how data flows within a network, regardless of its physical design
Transmission Control Protocol/Internet Protocol
TCP/IP (Transmission Control Protocol/Internet Protocol)
the basic communication language or protocol of the Internet. It can also be used as a communications protocol in a private network (either an intranet or an extranet)
The decision on which system to purchase should be:
a list of items to be discussed at a formal meeting
the practice of examining large databases in order to generate new information
a term used to refer to a kind of middleware application which is used to transform, route, clone and translate messages
Creating a demo of a new system
Legally authorized representative
An individual or judicial or other body authorized under applicable law to consent on behalf of a prospective subject to the subject's participation in the procedure(s) involved in the research
The principle of respect for persons can be broken down into two basic ideas:
- Individuals should be treated as autonomous agents
- Persons with diminished autonomy are entitled to additional protections
The three fundamental aspects of informed consent are:
Individuals’ decisions about participation in research should not be influenced by anyone involved in conducting the research: “...consent must be freely given or truly voluntary."
Individuals must have the mental or decisional capacity to understand the information presented to them in order to make an informed decision about participation in research.
The probability and magnitude of harm or discomfort anticipated in the research are not greater in and of themselves than those ordinarily encountered in daily life or during the performance of routine physical or psychological examinations or tests.
“...affirmative agreement to participate in research. Mere failure to object should not, absent affirmative agreement, be construed as assent.”
Office for Human Research Protections (part of HHS)
Two general rules have been articulated as complementary expressions of beneficent actions:
- Do no harm
- Maximize possible benefits and minimize possible harms
Risk (in research)
the probability that a certain harm will occur
Types of Risk (in research)
The proposed research has a favorable ratio of potential benefit to risk.
The tendency for research participants to: “downplay or ignore the risks posed to their own well-being by participation ... [due to] the participants deeply held and nearly unshakeable conviction that every aspect of their participation in research has been designed for their own individual benefit.”
Substantial scientific uncertainty about which treatments will benefit subjects most, or a lack of consensus in the field that one intervention is superior to another.
“...a prospective biomedical or behavioral research study of human subjects that is designed to answer specific questions about biomedical or behavioral interventions (drugs, treatments, devices, or new ways of using known drugs, treatments, or devices).”
being “free from unsanctioned intrusion.”
holding secret all information relating to an individual, unless the individual gives consent permitting disclosure.
Lacking “identifiers or codes that can link a particular sample to an identified specimen or a particular human being.”
Coded data (research)
Identifiers are removed from the data in exchange for codes that correspond to the identifiers, and the identifiers are maintained separately from the rest of the dataset.
Data and Safety Monitoring Plan
Describes protections for research participants and data integrity, and oversight for clinical trials at a level that is commensurate with the risks of participating in the clinical trial and is required by NIH.
a software architecture model consisting of two parts, client systems and server systems, both communicating over a computer network or on the same computer.
the software that supports a computer's basic functions, such as scheduling tasks, executing applications, and controlling peripherals.
an Internet site providing access or links to other sites
A survey of your patients has found that they want access to test results and the ability to schedule appointments online. What technology should be used to provide these services?
You use an information system to create a letter notifying a requester that your facility does not have any records on file for the individual's records requested. What system are you using?
release of information
Your release of information system has part of the computing on the workstation and part on the file server. What type of technology is being used?
keeps track of the location of all records in the health care facility.
Your role is to help patients determine where to store their personal health record. What area do you specialize in?
When calling the HIM Department, you say the word "two" to reach the release of information system. What technology is this?
interactive voice recognition
interactive voice recognition (IVR)
a technology that allows a computer to interact with humans through the use of voice and DTMF tones input via keypad.
voice over Internet protocol
an IP telephony term for a set of facilities used to manage the delivery of voice information over the Internet
A series of conversion steps that allow an organization to evolve smoothly to newer hardware and software in order to keep pace with changing technology.
a software testing methodology used to test individual software components or units of code to verify interaction between various software components and detect interface defects
a process by which application software developed for hand held mobile devices is tested for its functionality, usability and consistency
a test conducted to determine if the requirements of a specification or contract are met
testing a software application or the product with a certain amount of data
secure (someone) against legal responsibility for their actions
A common clause in contracts that essentially frees both parties from liability or obligation when an extraordinary event or circumstance beyond the control of the parties, such as a war, strike, riot, crime, or an event described by the legal term act of God (hurricane, flood, earthquake, volcanic eruption, etc.), prevents one or both parties from fulfilling their obligations under the contract.
a shared boundary across which two separate components of a computer system exchange information
a telecommunications network which allows computers to exchange data
a text listing of commands to be compiled or assembled into an executable computer program
Clinical Data Repository (CDR) or Clinical Data Warehouse (CDW)
a real time database that consolidates data from a variety of clinicalsources to present a unified view of a single patient.
the part of project planning that involves determining and documenting a list of specific project goals, deliverables, tasks, costs and deadlines
critical success factors
a management term for an element that is necessary for an organization or project to achieve its mission
in project management refers to uncontrolled changes or continuous growth in a project's scope
structured data entry
a data entry method by interacting with pre-defined forms
unstructured data entry
information that either does not have a pre-defined data model or is not organized in a pre-defined manner
What element is most critical in the contract negotiation to ensure use of the software in multiple environments?
A milestone is
a step in the path to the implementation of a system such as the EHR.
continuity of care record
a standard for the creation of electronic summaries of patient health
a plastic card with a built-in microprocessor, used typically for electronic processes such as financial transactions and personal identification
shows what the system should do
logical data model
shows how the logical data model will be created
physical data model
What data field type is best used for the health record number?
When negotiating an information system contract, what would be an example of a performance warranty specified in the contract?
radio frequency identification device
radio frequency identification device (RFID)
uses electromagnetic fields to automatically identify and track tags attached to objects
The most effective way to achieve data security. To read this type of file, you must have access to a secret key or password that enables you to decrypt it.
pedicled tram flap reconstruction
the surgeon cuts a section of skin, muscle, fat and blood vessels from your abdomen, tunnels the tissue underneath your skin to its new location, and uses it to form a new breast mound
There are two of these in the medial (inside) portion of each eye. Together, they function to collect tears produced by the lacrimal glands.
the surgical technique of cutting a slit into an abscess or cyst and suturing the edges of the slit to form a continuous surface from the exterior surface to the interior surface of the cyst or abscess
a raised growth on the skin resembling a wart, typically in the genital region, caused by viral infection or syphilis and transmissible by contact
Carotid endarterectomy (CEA)
a surgical procedure used to reduce the risk of stroke, by correcting stenosis (narrowing) in the common carotid artery or internal carotid artery.
a benign smooth muscle neoplasm that very rarely becomes cancer. They can occur in any organ, but the most common forms occur in the uterus, small bowel, and the esophagus.
the closure of the perforation of pars tensa of the tympanic membrane
Procedure in which the blood is filtered, separated, and a portion retained, with the remainder being returned to the individual.
the removal of blood plasma from the body by the withdrawal of blood, its separation into plasma and cells, and the reintroduction of the cells, used especially to remove antibodies in treating autoimmune diseases.
Individual justice (in research)
investigators “should not offer potentially beneficial research only to some patients who are in their favor or select only ‘undesirable’ persons for risky research.”
“The choice of participants in research needs to be considered carefully to ensure that groups (e.g., welfare patients, particular racial and ethnic minorities, or persons confined to institutions) are not selected for inclusion mainly because of easy availability, compromised position, or manipulability.”
to treat fairly
to treat in exactly the same way
Withholding some information in order to conduct an unbiased study, with the understanding that the information could be material to a decision by prospective participants about whether or not to participate in the study.
What type of test would determine how well new systems being implemented work with existing systems?
What system would provide a snapshot of information about the patient's condition?
continuity of care record
When negotiating an information system contract, what would be an example of a performance warranty specified in the contract?
clinical data repository
Data from the laboratory information system, radiology information system, and many other systems are all stored real-time in a single database
centralized health information exchange
all data is stored in a single warehouse or data repository and participants regularly submit patient data while being able to view the data through external delivery methods
federated health information exchange
all data stays at the point of service (POS) and the participant is a member of an organization and agrees to share their information with the other members of the organization (also known as decentralized)
hybrid health information exchange
When there is a mixture of centralized and decentralized models and none are the prominent architecture, it is considered Hybrid
The most secure model of signatures used in information systems
radio frequency identification
A technology that can be used to check on a patient who is homebound
integrated health network
A network of organizations that provides or arranges to provide a coordinated continuum of services to a defined population and is willing to be held clinically and fiscally accountable for the outcomes and health status of the population served
health information exchange
the mobilization of health careinformation electronically across organizations within a region, community or hospital system
a process that systematically surveys and interprets relevant data to identify external opportunities and threats. An organization gathers information about the external world, its competitors and itself
critical path analysis
the mathematical network analysis technique of planning complex working procedures with reference to the critical path of each alternative system
Cautious affiliation stage
the forming stage
the storming stage
harmonious cohesiveness stage
the norming stage
the performing stage
an effective tool for planning and tracking a project
Provides a structure that requires the project team to identify the order and projected duration of activities needed to complete a project.
the longest amount of time requied to complete the total project
The 3 phases of change
ending, transitioning, beginnning
(freezing, changing, refreezing)