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Exam 2 Terms in this set (59)Sentinel events Unexpected occurrences involving death or serious physical or psychological injury, or the risk thereof. quantitative analysis The goal of quantitative analysis is to make sure there are no missing reports, forms, or required signatures in a patient record. Timely completion of this process ensures a complete health record HIM professional's core ethical obligations are to protect patient privacy and confidential information and communication and to assure security of that information Secondary data is used in research Templates are a cross between free text and structured data entry The user is able to pick and choose data that are entered frequently, thus requiring the entry of data that change from patient to patient. Templates can be customized to meet the needs of the organization as data needs change by physician specialty, patient type (surgical/medical/newborn), disease, and other classification of patients. In this situation a template would provide structured data entry for the admission date Data integrity means data should be complete, accurate, consistent, and up-to-date. With respect to data security, organizations must put protections in place so that no one may alter or dispose of data in a manner inconsistent with acceptable business and legal rules A disclosure management system tracks the disclosures made throughout the healthcare facility for reporting purposes. Disclosure is the release, transfer, provision of access to, or divulging tin any manner of information outside the healthcare facility holding the information The process for expert determination of de-identification has four recommended steps that include: Step 1: The facility should choose the expert for the deidentification analysis; Step 2: Determine the statistical and scientific method to be used to determine the risk of reidentification; Step 3: The expert applies the method to the deidentified data; and Step 4: Analyze and assess the risk to the deidentified data Free-text data is the unstructured narrative data that is the result of a person typing data into an information system. It is undefined, unlimited, and unstructured, meaning that the typist can type anything into the field or document. Data mining is the process of extracting and analyzing large volumes of data from a database for the purpose of identifying hidden and sometimes subtle relationships or patterns and using those relationships to predict behaviors Aggregate data s data extracted from individual health records and combined to form de- identified information about groups of patients that can be compared and analyzed If an employee produces 2,080 hours of work in the course of one year, how many employees will be required for the coding area if the coding time on average for
one record is 30 minutes and there are 12,500 records that must be coded each year? The number of records per FTE is 2 (number of records per hour) × 2,080 = 4,160. Therefore, three employees per year are required: 12,500 / 4,160 = 3.0 Information assets refer to the information collected during day-to-day operations of a healthcare organization that has value within an organization. For example, patient data collected to support patient care is an example of information assets for the organization Work measurement is based on assessment of internal data collected on actual work performed within the organization and the calculation of time it takes to do the work Sampling is the recording of a smaller subset of observations of the characteristic or parameter, making certain, however, that a sufficient number of observations have been made to predict the overall configuration of the data type of distribution are the mean, median, and mode equal d. Normal distribution Heatmap A heat map plots all data points as a cell for two given variables or interest, and depending on frequency of observations in each cell, provides color to visualize high or low frequency Workload statistics assist managers with the tasks of monitoring productivity and provide data regarding resources used, such as equipment, personnel, services, and supplies MS-DRG system he CMI is the average of the relative MS-DRG weights of all cases treated at a given hospital. The CMI can be used to make comparisons between hospitals and to assess the quality of documentation and coding at a particular hospital part of qualitative analysis review Qualitative analysis is about the quality of the documentation including the use of approved abbreviations Healthcare abuse relates to practices that may result in: Performing medically unnecessary services A corporate integrity agreement (CIA) is essentially a compliance program imposed by the government, with substantial government oversight and outside expert involvement in the organization's compliance activities. The OIG negotiates CIAs with health care providers and other entities as part of the settlement of federal health care program investigations arising under a variety of civil false claims statutes. Providers or entities agree to the obligations, and in exchange, OIG agrees not to seek their exclusion from participation in Medicare, Medicaid, or other federal healthcare programs A firewall is a part of a computer system or network that is designed to block unauthorized access while permitting authorized communications. It is a software program or device that filters information between two networks, usually between a private network like an intranet and a public network like the Internet In
this experimental study, blood pressure is taken before and after an experimental medication is used as the intervention in a sample of participants that were previously unable to control their blood pressure with other medications. In this example, the independent variable is the __________ and the dependent variable is the__________. Experimental medication; blood pressure independent variable the intervention used (medication) dependent variable disease that is being assessed (blood pressure) purged means removed and sent to storage Which of the following would be considered a security vulnerability? Lack of laptop encryption A security threat s anything that can exploit a security vulnerability. Vulnerability is a weakness or gap in security protection. In this situation the lack of encryption for the laptop would be considered a security vulnerability as the contents could be more easily accessed Which of the following coding error classifications is most valuable in determining the impact on overall revenue cycle? Errors that produced changes in MS-DRG assignment The link that tracks patient, person, or member activity within healthcare organizations and across patient care settings is known as: Correct Answer: A The EMPI is a list or database created or maintained by a healthcare facility to record the name and identification number of every patient and activity that has ever been admitted or treated in the facility. When a healthcare enterprise as more than one facility and the patient is seen at two or more places, the enterprise master patient index (EMPI) links the patient's information at the different facillities Which of the following is not a recommended guideline for
maintaining integrity in the health record? Ensuring documentation that is being changed is permanently deleted from the record Data integrity is the assurance that the data entered into an electronic system or maintained on paper are only accessed and amended by individuals with the authority to do so. Data integrity includes data governance, patient identification, authorship validation, amendments and record correction, and audit validation for reimbursement purposes. These functions ensure that the data is protected and altered by authorized individuals as per policy. Assuring documentation that is being changed is permanently deleted from the record would not be a guideline for maintaining the integrity of the health record OIG has published several documents to help providers develop internal programs that include elements for ensuring compliance. One of the elements included is written policies and procedures Edit checks assist in ensuring data integrity by allowing only reasonable and predetermined values to be entered into the computer spoliation the act of destroying, changing, or hiding evidence intentionally coder assigned separate codes Unbundling The leader of the coding performance improvement team wants all her team members to clearly understand the coding process. Which of the following would be the best tool for accomplishing this objective? Flow chart AHIMA's principles Accountability and integrity database the LAST_NAME column in a table would be considered a Data element When an individual requests a copy of the PHI or agrees to accept summary or explanatory information, the covered entity may: a. Impose a reasonable cost-based fee If steps in a revenue cycle process are handled separately in sequence by individual workers, the method of organizing work is called which of the following? Serial work division One of two major ways to organize process work is serial work division, assembly line fashion, where tasks or steps are handled separately in sequence by multiple individuals In developing an internal coding audit review program, which of the following would be risk areas that should be targeted for audit? Chargemaster description and medical necessity The APC assignment for a procedure or services does not change based on the patient's medical condition or the severity of illness The number of APC assignments is based on the number of reimbursable procedures or services provided for that patient. In this instance, the patient has five APCs The three elements of a security program are ensuring data availability, protection, and: Integrity Which of the following ethical principles is being followed when a health information management professional ensures that patient information is only
released to those who have a legal right to access it? Beneficence A hospital's EHR defines the expected values of the gender data element as female, male, and unknown. This type of specificity is known as: Data precision Data precision is the term used to describe expected data values. As part of data definition, the acceptable values or value ranges for each data element must be defined. For example, a precise data definition related to gender would include three values: male, female, and unknown One strategy in protecting the organization's data is to establish a risk management program. Risk management encompasses the identification, evaluation, and control of risks that are inherent in unexpected and inappropriate events Patient name, zip code, and health record number are typical: Data elements maintain patient identity data integrity The data must be accurately queried A dietary department donated its old laptop to a school. Some old patient data were still on the computer. What controls would have minimized this security breach? Device and media controls Device and media controls require the facility to specify proper use of electronic media and devices (external drives, backup devices, etc.). Included in this requirement are controls and procedures regarding the receipt and removal of electronic media that contain protected health information and the movement of such data within the facility. The entity must also address procedures for the transfer, removal, or disposal, including reuse or redeployment, of electronic media
check sheet is used to gather data based on sample observations in order to detect patterns. When preparing to collect data, a team should consider the four W questions: Who will collect the data? What data will be collected? Where will the data be collected? When will the data be collected? line graph used to display time trends. A line graph is especially useful for plotting a large number of observations. It also allows several sets of data to be presented on one graph MEDPAR frequently used for research on topics such as charges for particular types of care and MS-DRGs. The limitation of the MEDPAR data for research purposes is that the file contains only Medicare patients credentialing process Medical staff bylaws Other sets by this creatorEnglish Words Most Commonly Mistake2 terms squigtar Parts of Speech4 terms squigtar English Words and Definition19 terms squigtar English Pronounciation5 terms squigtar Recommended textbook solutionsClinical Reasoning Cases in Nursing7th EditionJulie S Snyder, Mariann M Harding 2,512 solutions
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Which of the following is not a recommended guideline for maintaining integrity in the health record quizlet?
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