Term
| Allied health professional |
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Definition
| a credentialed healthcare worker who is not a physician, nurse, psychologist, or pharmacist (for example, a physical therapist, dietitian, social worker, or occupational therapist) |
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| Accreditation organization |
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Definition
| a professional organization that establishes the standards against which healthcare organizations are measured and conducts periodic assessments of the performance of individual healthcare organizations |
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| Centers for MEdicare and Medicaid Services (CMS) |
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| the division of the Department of Health and Human Services that is responsible for developing healthcare policy in the US and for administering the Medicare program and the federal portion of the Medicaid program and maintaining the procedure portion of the International Classification of Diseases, 9th revision, Clinical Modification (ICD-9-CM); called teh Health Care Financing Administration (HCFA) prior to 2001 |
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| the healthcare worker responsible for assigning numeric or alphanumeric codes to diagnostic or procedural statements |
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| a legal and ethical concept that establishes the healthcare provider's responsibility for protecting health records and other personal and private information from unauthorized use or disclosure |
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-the dates, numbers, images, symbols, letters, and words that represent basic facts and observations about people, processes, measurements, and conditions;
-in healthcare organizations, falls into one of three categories: patient-specific, aggregated, or comparative |
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| the extent to which healthcare data are obtainable |
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| the extent to which data are free of identifiable error |
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| the extent to which healthcare data are complete |
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| the extent to which the healthcare data is valid, accurate, usable and has integrity, so that each end user has a consistent view of the data |
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| the extent to which data are up-to-date |
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| the specific meaning of a healthcare-related data element |
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| the level of detail at which the attributes and values of healthcare data are described |
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| the extent to which data have the values they are expected to have |
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| a managerial process that ensures the integrity (accuracy and completeness) of an organization's data during data collection, application, warehousing, and analysis |
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| the extent to which healthcare-related data are useful for the purpose for which they are collected |
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same as 'data currency'
the extent to which data are up-to-date |
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Definition
| numeric or alphanumeric characters used to classify and report diseases, conditions, and injuries |
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Term
| Electronic health record (EHR) |
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Definition
| an electronic record of health-related information on an individual that conforms to nationally recognized interoperability standards and that can be created, managed, and consulted by authorized clinicians and staff across more than one healthcare organization |
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Term
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Definition
1. a paper- or computer-based tools for collecting and storing information about the healthcare services provided to a patient in a single healthcare facility; also called a patient record, medical record, resident record, or client record, depending on the healthcare setting
2. individually identifiable data, in any medium, that are collected, processed, stored, displayed, and used by healthcare professionals; documents the care rendered to the patient and the patient's healthcare status |
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Definition
| data that have been deliberately selected, processed, and organizaed to be useful |
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| Integrated health record format |
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Definition
| a system of health record organization in which all the paper forms are arranged in strict chronological order and mixed with forms created by different departments |
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| Integrated health record format |
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Definition
| a system of health record organization in which all the paper forms are arranged in strict chronological order and mixed with forms created by different departments |
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Term
| Problem-oriented health record format |
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Definition
| a health record documentation approach in which the physician defines each clinical problem individually |
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| the numeric or alphanumeric characters used to classify and report the medical procedures and services performed for patients |
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| Quality improvement organizations (QIOs) |
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Definition
| an organization that performs medical peer review of Medicare and Medicaid claims, including a review of validity of hospital diagnosis and procedure coding information; completeness, adequacy, and quality of care; and appropriateness of prospective payments for outlier cases and nonemergent use of the emergency room; until 2002, called peer review organization |
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Definition
| Compensation or repayment for healthcare services |
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| Source-oriented health record format |
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Definition
| a system of health record organization in which information is arranged according to the patient care department that provided the care |
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Definition
| an insurance company (for example, Blue Cross/Blue Shield) or healthcare program (for example, Medicare) that pays or reimburses healthcare providers (second party) and/or patients (first party) for the delivery of medical services |
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Definition
| a specially trained typist who understands medical terminology and translates physicians' verbal dictation into written reports |
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| Utilization management organization |
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| an organization that review the appropriateness of the care setting and resources used to treat a patient |
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| How Many Times Something Happened (numerator)/How Many Times it Actually Happened (Denominator) |
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| A Simple Calculation of Dividing One Quantity by another: x/y |
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A proportion is a type of ration - but 'x' becomes a portion of the whole:
x/(x+y) |
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Definition
-A rate is used to measure an event over a period of time.
-Basic formula for calculating a rate:
Number of cases occurring during a given period of time
-Total cases or population at risk during the same time period |
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Definition
A percentage is determined by multiplying your numerator by 100. So for example, to get a percentage out of the equation 5/1000, you would change the equation. to 5x100/1000, which is equal to 5%.
(I think you can also divide the numerator by the denominator, as in 5 divided by 1000) |
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Term
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Definition
| The inpatient census tells you how many patients are present in your facility at one particular point in time. Most facilities take the count of patients present in their facility at a consistent time each day – usually at midnight. |
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Definition
| Daily inpatient census describes something a bit different. This not only tells you how many patients were present at the census taking hour, but also how many patients were admitted and discharged during a 24-hour period beginning and ending at the census taking hour. |
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| Daily Inpatient census: example |
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Definition
| EXAMPLE: Each patient care unit counts the number of inpatients present in the facility at midnight, at the end of the day on Dec. 1. The total patients present were 100. During Dec. 2nd, 3 patients were admitted but one of these patients expired 5 hours after being admitted. The daily inpatient census for December 2nd was 103. |
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Term
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Definition
| An inpatient service day is a unit of measure denoting the services that you provided to one inpatient in one 24-hour period. This 24-hour period is the time between the census taking hours. |
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| Inpatient Services days: example |
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Definition
EXAMPLE: On June 1, at midnight at the end of the day the patient census was 240.
Number of patients admitted on June 2 = 40
Number of patients discharged on June 2 = 35
Number of patients admitted and discharged on June 2 = 3
Patient census on June 2 at midnight = 245
Inpatient services days for June 2 = 248
240 + 40 [admissions] = 280 – 35 [discharges] = 245 Patient Census at next census taking hour.
245 +3 [patients admitted and discharged] = 248 inpatient service days |
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Term
| AVERAGE daily inpatient census |
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Definition
The hospital can compute inpatient service days on a daily, weekly, monthly or yearly basis.
The formula to calculate the average daily inpatient census for a period:
Total # of INPT service days (given period)/
Total number of days in the period
The average daily inpatient census can be determined for the hospital as a whole, or each inpatient unit. |
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| AVERAGE daily inpatient census: example |
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Definition
EXAMPLE: Calculation of average daily inpatient census: A hospital with 100 beds had 2,500 inpatient service days for the month of June.
Set up formula:
2500 inpatient service days
= 83.3
30 days [days in the month of June]
The average daily census for the month of June was 83.3. |
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Term
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Definition
Length of stay is an important calculation. The length of stay for each patient is calculated after the patient is discharged. It is based on calendar days from the time the patient was admitted to his/her day of discharge. Subtract the date of admission from the date of discharge.
EXAMPLE: Length of stay
Patient was admitted on January 2 and discharged on January 10.
The length of stay for this was patient was 8 days (10 – 2 = 8). |
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Term
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Definition
refers to the length of stay for all patients discharged during a given a time period.
EXAMPLE: Total length of stay
Ten patients had the following length of stays:
4,2,5,4,3,6,3,7,1,3
The total length of stay for these patients was 38 days. |
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Term
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Definition
The average length of stay is the total length of stay divided by the number of patients discharged.
EXAMPLE: Average length of stay
The average length of stay of those ten patients with a total length of stay of 38 days:
38/10 = 3.8 days |
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Definition
| ancillary function of health record |
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Term
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Definition
| an attempt to contain hospital INPT cost and improve quality by restructuring services |
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Definition
| data collection tool used when one need to gather data on sample observations in order to detect patterns |
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Term
| The % of antibiotics administered immediately prior to ORIF surgeries or the % of de.liveries accomplished by CSection are examples of what type of performance measure? |
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Definition
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| type of performance measure indicates the results of the perfomrance or non-performance of a function or process |
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| an example of the interrelated activities in HCO that promote effective and safe patient outcomes across services and disciplines w/in an integrated environment |
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Term
| The Tax Relief and Health care Act 2006 (IMIEA-TRHCA) expanded CMS quality initiatives to which two sttings? |
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Definition
| Hospital OPT dpts and Amb Surgical Ctr. |
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Term
CAHIIM housed in
Health Information Managment Association |
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Definition
| education accrediting body |
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Term
| Clinical Privileges by Medical Staff |
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Definition
| permission to provide clinical services and outlines their scopes of practice w/in an organization |
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| are legally binding medical staff operating policies that voted upon by medical staff |
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Definition
faciity-based or population-based
secondary data source |
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Definition
Cancer
Trauma
Communicable Disease
Birth Defect
Implant |
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Term
| Case definition in Cancer Registry |
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Definition
| process of deciding what cases should be entered in the registry |
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Term
| Case finding in Cancer Registry |
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Definition
| several ways to do this incl. d/c process in HIM dept. and diagnosis assignement, like pathology report review, cancer related treatment reports, etc. |
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Term
| Assigning as Accession Number in Cancer Registry |
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Definition
| number is structured w/ the year and case number (ie, 09-020 = represent 20th cancer case entered in the registry during theyear 2009) |
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| Abstracting in Cancer Registry |
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Definition
| of demographics data, types and sites of cancer, diagnostic methods, tratment methods, stage of cancer at the time of diagnosis |
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Term
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Definition
| case definition, case finding, assigning accession #, abstracting information, SEER and TNM cancer staging, Use of ICD-O (oncology), lifetime follow up |
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