Term
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Definition
| include data on births, deaths, fetal deaths, marriages and divorce |
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Definition
| responsible for collection of vital statistics |
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Term
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Definition
| a chronological listing of patient with a common characteristic. |
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Definition
| describing the patients that are to be included in Registry |
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Term
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Definition
| Identifying patients that are to be included on a registry |
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Term
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Definition
| extracting the information to be included from health records on a registry |
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Term
| Agency for Healthcare Research and Quality (AHRQ): |
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Definition
| an agency within HHS, aims to improve the quality, safety, efficiency and effectiveness of healthcare for all Americans. |
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Term
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Definition
| Function is to support health services research |
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Term
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Definition
| the health record- because it contains patient specific information and data that has been documented by the professionals who provide patient care |
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Term
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Definition
| Data taken from the health records and entered into registries and databases |
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Term
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Definition
| Internal (within healthcare facility) and external users |
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Term
| Ambulatory Surgical Centers |
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Definition
| patients are classified as outpatients and are released from surgery center on same day that procedure is performed |
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Term
| Ambulatory Surgical Centers |
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Definition
| accreditation from: JC, Accreditation Association for Ambulatory Health Care (AAAHC), & American Association for Ambulatory Surgery Facilities (AAAASF) |
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Term
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Definition
| provide delivery services for women who plan to have normal deliveries |
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Term
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Definition
| Specialize in providing comprehensive cancer treatment, including radiation and chemotherapy and offer patient education and family counseling |
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Term
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Definition
| Established by the American College of Surgeons, the Commission on Cancer, sets standards for quality multidisciplinary cancer care |
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Term
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Definition
| located in low income neighborhoods and offer comprehensive, primary healthcare services to patients who are limited to healthcare |
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Term
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Definition
| operated by local and state public health departments and most services are provided by public health nurses |
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Term
| Correctional Facilities Health Clinics |
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Definition
| inmates are given a screening once arriving in correctional facilities and there is no informed consent or payment required for treatment |
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Term
| Diagnostic Imagining Centers |
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Definition
| provides diagnostic imaging services including MRI, CT, PET, Ultrasound, nuclear medicine, molecular imagining, and digital mammography |
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Term
| Industrial Health Clinics |
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Definition
| offer treatment to workers who are affected by work related injuries and illnesses. Financed through workers compensation |
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Term
| Health Maintenance Organizations |
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Definition
| offer wide range of healthcare services, and provide coverage to voluntarily enrolled individuals in return for prepayment of a fixed fee |
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Term
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Definition
| designed to evaluate and treat conditions that are not severe enough to require treatment in a hospital emergency department but still require treatment beyond normal physician office hours |
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Term
| SOMR- Source Oriented Medical Record |
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Definition
| Lab results grouped together, radiology notes grouped together, etc. The more departments an org has, the more sections the record will have. |
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Term
| SOMR- Source Oriented Medical Record |
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Definition
| Record Format grouped by point of origin and sequentially |
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Term
| Problem Oriented Medical Record (POMR) |
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Definition
| Arranged according to patient's problem list (past and present social, psych, or medical problems) |
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Term
| POMR- Problem oriented Medical Record |
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Definition
| Record Format that uses problem list that is indexed (each problem has unique number) and all documentation is keyed to it chronological or reverse order; SOAP notes |
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Term
| Integrated (Record Format) |
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Definition
| record format for paper-based records. Documentatino sources are intermingled and arranged in strict chronological or reverse chronological order. |
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Term
| Disadvantage of Integrated Record Format |
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Definition
| difficult to compare related information in patient record |
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Term
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Definition
| o Documents the basic demographic data collected before or during the initial patient visit |
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Term
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Definition
| o This information is updated and maintained on subsequent visits and UACDS is frequently used as a baseline |
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Term
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Definition
| Uniform Ambulatory Care Data Set |
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Term
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Definition
| single page summarizes all the major medical and surgical problems that have long term clinical significance for the patient |
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Term
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Definition
| o Ongoing record of the medications a patient has received in the past and is taking currently |
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Term
| Patient History Questionnaire |
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Definition
| o Structured to prompt the patient to provide certain items of information , including the presence or absence of significant conditions that may represent potential medical problems |
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Term
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Definition
| o Foundation for care, must be comprehensive, & frequency depends on age and health status |
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Term
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Definition
| o Content: 1. Chief complaint (reason for visit) 2. Present illness 3. Past history 4. Social history 5. Family history 6. Review of systems 7. Immunizations |
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Term
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Definition
| o Summary of patient status & treatment. Completed for each encounter. Structured or Narrative. Legible, uniform |
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Term
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Definition
| Subjective, Objective, Assessment, Plan |
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Term
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Definition
| patient complaints in own words |
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Term
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Definition
| physical findings & lab data |
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Term
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Definition
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Term
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Definition
| Medications, therapy, referral, consult, education |
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Term
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Definition
| instructions from physicians to others. Medications, services, diagnostic tests, treatments. Must be signed and dated. Standing orders for routine care |
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Term
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Definition
| o Clear instructions must be given to the patient both verbally and in writing, with a copy of the written instructions in health record |
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Term
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Definition
| o In ambulatory care, the patient assumes responsibly for care |
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Term
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Definition
| Protects org from litigation about compliance w/standards of care. Demonstrates patient compliance or not. Document attempts to contact and advise |
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Term
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Definition
| Document advice and follow-up. Date+time, reason for call, signature of staff returning call all documented. |
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Term
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Definition
| Important for risk management and quality patient care |
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Term
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Definition
| Subjective, Objective, Assessment, Plan, Intervention, Evaluation |
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Term
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Definition
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Term
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Definition
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Term
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Definition
| an unexpected occurrence involving death or serious physical or phychological injury or the risk thereof (i.e. operating on wrong side of body, leaving sponge or foreign body in patient afer surgery, patient fall resulting in death) |
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Term
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Definition
| Main difference between hospital and LTCH is |
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Term
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Definition
| subject to requirements of the LTCH prospective payment system |
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Term
| LTCH Medicare Reimbursement |
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Definition
| · under PPS based on the Medicare DRG system used by short term acute care hospitals and referred to as LTC-DRGs |
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Term
| Quality Improvement Organization |
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Definition
| Review medical necessity, reasonableness and appropriateness of hospital admissions and discharges |
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Term
| Quality Improvement Organization |
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Definition
| Review Inpatient hospital care for which outlier payments are sought |
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Term
| Quality Improvement Organization |
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Definition
| Review validity of hospital’s diagnostic and procedural information |
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Term
| Quality Improvement Organization |
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Definition
| Review completeness adequacy and quality of services furnished in he hospital |
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Term
| Quality Improvement Organization |
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Definition
| Review medical or other practices with respect to beneficiaries or billing for servies furnished to the beneficiaries |
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Term
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Definition
| Clarify principal and secondary diagnoses if ambiguous, conflicting or incomplete |
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Term
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Definition
| Form developed from AHIMA’s standards for ethical coding and official guidelines |
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Term
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Definition
| • Developed by medical staff with coding professionals |
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Term
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Definition
| Determine what is valid query and policies, procedures, processes |
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Term
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Definition
| o Should reflect the reason patient is being admitted to the long term care setting “condition after study for occasioning the admission to LTCH” |
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Term
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Definition
| o Plan of Care/Impression= must include specific treatments and services o be provided |
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Term
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Definition
| o Include clear rational for admission and continued stay in LTC |
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Term
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Definition
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Term
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Definition
| Snapshot of patient's status - dictates care to be provided, SOAPIE notes for each problem |
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Term
| Functional Independence Measures |
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Definition
| Are completed in come LTCH settings because of the focus of care is on extensive rehab of the patient. |
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Term
| Functional Independence Measures |
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Definition
| there are 18 items to be measured |
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Term
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Definition
| the level of independence is scored on a scale of 1 to 7 ( 1= most dependent, 7=independent) |
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Term
| LTCH Accreditation Standards & Regulations |
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Definition
| Same Federal and accrediting standards as acute care. o JC, AOA, CARF, Medical staff bylaws & regulations just follow Medicare COP |
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Term
| Skilled Nursing Facility (SNF) |
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Definition
| requires skills of qualified individual for medical & nursing care= ventilator, complex wound care, IV therapy, feeding tube |
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Term
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Definition
| Minumum Data set- same functions as acute care |
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Term
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Definition
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Term
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Definition
| · Pre admission screening assessment |
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Term
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Definition
| less skilled care for dressing, hygiene. Most patient are considered permanent residents |
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Term
| Resident Assessment Manual |
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Definition
| o Helps nursing home staff gather information on a resident’s strengths and needs, which must be addressed in an individualized care plan |
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Term
| Resident Assessment Manual |
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Definition
| assists staff with evaluating goal achievement and revising care plans accordingly by enabling the nursing home to track changes in the resident’s status |
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Term
| Resident Assessment Manual |
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Definition
| o Content of RAIs is determined by each state, but the Minimum Data Set is set by CMS |
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Term
| Resident Assessment Instrument (RAI) |
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Definition
| Components: MDS, RAPs (Resident Assement Protocols), Utilization Guidelines. May include nutritional assesment, cognitive assessment, nursing assessment, pastoral care, etc |
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Term
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Definition
| · A core set of screenings, clinical and functional status elements to use as a standardized means of assessing all residents in CMS facilities |
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Term
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Definition
| • Is a primary document in the resident’s health record |
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Term
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Definition
| • Required for Medicare and Medicaid participation |
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Term
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Definition
| • Used to plan ongoing care and treatment |
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Term
| Resident Assessment Protocol |
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Definition
| a federally mandated assessment - includes long term care resident's care plan. Ensure complete care planning process |
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Term
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Definition
| o MDS item responses ‘trigger’ target conditions for additional assessment and review |
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Term
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Definition
| o Used to further define the needs of the resident (than MDS). Make sure Treatment is comprehensive |
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Term
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Definition
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Term
| Care area Triggers (CATs) |
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Definition
| o RAPs were changed to CATs when MDS 3.0 was launched in July 2010 |
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Term
| Care area Triggers (CATs) |
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Definition
| o The 18 RAPs were replaced with 20 CATs – same but Paint and Return to the Community Referral added |
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Term
| Care area Triggers (CATs) |
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Definition
| o change the way facilities approach the documentation. The summary includes an instruction to describe the nature of the condition, complicating factors, risks and referrals for the resident’s problem area |
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Term
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Definition
| includes: home health agencies, home care, personal-care providers, and hospices |
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Term
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Definition
| Outcome and Assessment Information Set |
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Term
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Definition
| a group of data elements that represent core items in a comprehensive assessment for an adult home care patient |
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Term
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Definition
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Term
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Definition
| Condition of Participation. |
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Term
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Definition
| Reflects current health status and progress towards goals; shows continuing need for home care |
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Term
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Definition
| Meets patient’s medical, nursing, rehab, social, and discharge planning needs. Plan of care reviewed and updated |
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Term
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Definition
| patient and family assessment performed, involves a psychosocial assessment of patient and family needs and spiritual assessment. Pain assessment is perfomed when patient is experiencing pain to document effectiveness of pain medication |
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Term
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Definition
| it is important to know what makes a patient eligible for this, and how to document provision of care |
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Term
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Definition
| the Code of Federal Regulations – defines this benefit and documentation requirements |
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Term
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Definition
| Patients can elect this benefit at any time. Periods are * Initial 90 day period * Subsequet 90 day period * The subsequent extension of an unlimited number of 60 day periods when the patient is certified terminally ill with 6month prognosis if the disease run its normal course |
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Term
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Definition
| patient must have a physician certified terminal illness, a written certification must be obtained for each of the four month periods in the preceeding list a d tbe certification must indicate a life expectancy of less than six months |
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Term
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Definition
| Terminal diagnosis must be listed as principle diagnosis |
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Term
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Definition
rountine home care
continuous home care
impatient respite care
general inpatient care |
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Term
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Definition
| defined roles under the supervision of hospice employees |
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Term
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Definition
| must be trained and be used in administrative of direct patient care roles |
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Term
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Definition
| hospice must document cost savings from using volunteers |
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Term
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Definition
| write notes after each visit and include them in the hospice record (notes=new issues, special concerns, significant changes, volunteer’s response to interventions, volunteers plan for next contact and request for special consultation from staff) |
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Term
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Definition
| provided to family or caregiver after patient’s death |
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Term
| Bereavement Documentation |
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Definition
| does not necessarily have to be contained in the clinical record, bu must be maintained by the hospice in an organized, easily retrieavable manner |
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Term
| Bereavement Documentation |
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Definition
| hospice record includes the initial and follow up bereavement assessment of the family and significant others that documens the physical and emotional status of he family |
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Term
| Bereavement Documentation |
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Definition
| Initial assessment at team meeting, follow-up within 4 weeks of patient's death, additional meetings as needed |
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Term
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Definition
| Beneficiary must be confined to home |
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Term
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Definition
| Beneficiary is under the care of a physician, who establishes and approves the plan of care for the individual |
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Term
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Definition
| Beneficiary needs intermittent, skilled nursing care, physical therapy, speech therapy services, or continuing |
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Term
| Medicare Home Care Surveys |
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Definition
| use medical, nursing and rehab care indicators to determine the quality of a patient’s care and he scope of the home health agency services |
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Term
| Medicare Home Care Surveys |
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Definition
| use CMS Home Health Functional Assessment to document data from home care record reviews and patient visits |
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Term
| Medicare Home Care Surveys |
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Definition
| medicare guideline CoP instructs surveyors on presurvey and on site survey activity related to OASIS daa collection |
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Term
| Medicare Home Care Surveys |
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Definition
| Before survey, surveyors check with state OASIS education and review OASIS data management reports to determine whether encoding is completed within 7 days of completing OASIS Data set |
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Term
| OASIS Patients Documentation |
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Definition
| medicare CoP requires that the comprehensive assessment must be completed in a timely manner, consistent with the patient’s needs, but no later than five calendar days after the start of care |
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Term
| Documentation of PPS and OASIS |
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Definition
| Every month agencies must electronically report all OASIS data collected on all applicable patients in a format that meets CMS standards |
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Term
| Quantitative Record Review |
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Definition
| should be conducted at regular intervals and ensures that the required documentation is present, consistent, accurate and timely |
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Term
| Quantitative Record Review |
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Definition
| health records to be reviewed on admission and discharge and on a regular basis – every 30 -60 days |
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Term
| Quantitative Record Review |
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Definition
| agencies should review about 5% of their discharges |
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Term
| Documents that should be monitored concurrently |
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Definition
| documentation generating charges, documentation for any physician charges, & documentation for ancillary service billing |
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Term
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Definition
| State survey agencies and HHAs have access to adverse event outcome reports |
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Term
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Definition
| state survey agencies review available reports prior to going on site as part of their survey preparation |
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Term
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Definition
| the reports help suveyors identify areas of focus during the onsite survey |
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Term
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Definition
| help to improve HHAs to improve performance and determine if any adverse evens was due to noncompliance with the Conditions of Participation |
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Term
| Service Models for Behavioral Health |
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Definition
| *Inpatient 24/7 *Partial Stay (hospitalization) *Day treatment *Residential *Outpatient *Community Health *EAP *Schools/Universities |
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Term
Partial Stay (hospitalization) or day treatment
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Definition
| more intensive than outpatient services |
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Term
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Definition
| group homes/foster homes to foster independence |
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Term
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Definition
| OP, Homeless shelters, offices, clinics, homes |
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Term
| NCCBH (Community Behavioral Health) |
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Definition
| • National Council for Community Behavioral Healthcare |
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Term
| NCCBH Principles for recording information on consumers |
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Definition
| Reflect strength's, competencies, problems, and needs. Recognize family strengths. Respectful language. Be treated as mechanism for enhancing communication |
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Term
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Definition
| employee assistance programs |
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Term
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Definition
| employers ofter mental health services to their employees. Designed to provide immediate access to psychological counseling on a limited basis and may be provided on-site or by local providers |
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Term
| o Schools/Universities (BH) |
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Definition
| guidance, counseling, formal clinics, collaboration with community providers, crisis therapy; covered by HIPAAA and FERPA |
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Term
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Definition
| must comply with Medicare regulations, state laws and accreditation standards |
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Term
| Seclusion and restraints Requirements |
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Definition
| Show medical necessity; licensed physician order (most states); time limits + continuous observation |
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Term
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Definition
| Only if dangerous to self or others |
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Term
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Definition
| also referred to as process notes and they capture the therapist’s impressions of the client obtained from conversations during counseling sessions |
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Term
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Definition
| contain notes that are inappropriate for the inclusion in a medical record |
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Term
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Definition
| exclude notes on: medication, prescriptions, monitoring information, counseling sessions start and stop times, summary of diagnosis, functional status, treatment plan, symptoms, prognosis, and progress to date |
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Term
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Definition
| To qualify : must contain extended direct quotations from client and therapist, must include repeated and systematic reference to interpretive insights, must weave together patients past conflicts and issues with current difficulties |
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Term
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Definition
| o Placed under the care of an appointed guardian |
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Term
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Definition
| • Person is unable to provide food, shelter, clothing and other personal needs as a result of mental disorder and unwilling or unable to accept voluntary treatment |
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Term
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Definition
| Requirements vary state to state; acceptable documents created by attorneys and courts; documents become part of medical record |
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Term
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Definition
| identifies the client’s physical, cognitive, behavioral, emotional and social status |
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Term
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Definition
| identifies facilitating factors and possible barriers that prevent the patient from reaching heir goals beyond the presenting problems |
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Term
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Definition
| types: abuse reports, tuberculosis, HIV, STD, legal/police reports, duty to warn- |
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Term
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Definition
| mental health professionals have a duty to warn reasonably identifiable victim when there are known serious threats of violence against them |
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Term
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Definition
| Quality Improvement Organizations |
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Term
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Definition
| operates under the funding of CMS |
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Term
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Definition
| To assess and improve the quality of healthcare provided to consumers |
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Term
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Definition
| perform retropective record reviews, conduct national and local quality improvement studies and investigate consumer complaints regarding the quality of care provided in a number of settings |
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Term
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Definition
| do not specially review mental health facilities – however care provided to inidividuals wih mental illness is monitored in other settings with behavioral healthcare is sought |
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