Midterm Exam Review

This set of flashcards covers important topics related to health information management, hospital accreditation, patient care documentation, medical terminology, and ethical considerations.

What organizations accredit hospitals?

Joint Commission, DNV (Det Norske Veritas), or American Osteopathic Association Health Facilities Accreditation Program (AOA HFAP)

What are the requirements for CMS certification called?

Conditions of Participation

Who is deemed status granted to?

Accredited hospitals by CMS, meaning they automatically meet CMS conditions of participation.

Which organization accredits HIM educational programs?

CAHIIM - Commission for Accreditation of Health Informatics and Information Management Educational Programs

What is demographic information in a medical record?

Identifying information about the patient, typically found in the administrative documents of the record.

What does CC stand for in medical history?

Chief Complaint (what brought the patient to the hospital)

What does HPI stand for?

History of Present Illness (summary of the patient's current health issue)

What is the definition of Social History (SH) in a medical record?

Information about lifestyle factors, such as occupation, alcohol, tobacco, and drugs used.

What is deemed as the principal diagnosis?

The diagnosis that caused the admission to the hospital.

What is meant by complication in a medical context?

A condition that arises after admission, considered a type of secondary diagnosis.

What type of diagnosis is diabetes if present at admission?

Comorbidity - another illness or condition existing alongside the principal diagnosis.

What is the purpose of physician orders?

Physicians are responsible for directing patient care.

When are consents typically used in patient care?

During admission, before special procedures, and before experimental treatments.

What degrees are required for RHIT and RHIA?

RHIT requires an associate degree; RHIA requires a bachelor's or master's degree.

What is the continuing education requirement for RHIA?

30 continuing education units every 2 years.

What does AHIMA stand for?

American Health Information Management Association.

What does diagnostic imaging include?

X-ray, CT scan, MRI, and ultrasound.

What does ECG stand for?

Electrocardiogram - it traces the heart's electrical activity.

What is the most important part of the Code of Ethics in health information management?

Protect the privacy of patient information.

How often should physician progress notes be written?

Daily or more frequently if the patient’s condition warrants.

What are the vital signs?

Temperature, pulse, blood pressure, respiration.

What does p.o. signify on a medication order?

Per os, meaning by mouth.

What are the components of a complete medication order?

Name of the medication, dose, frequency, method of administration, start/stop dates.

What does DX stand for in medical terminology?

Diagnosis.

What is the legislative body of AHIMA called?

House of Delegates.

How is the physician training levels sequenced from lowest to highest?

Bachelor's degree student, medical student, intern, resident, fellow.

What does Public Law 89-97 (1965) establish?

Medicare and Medicaid.

What defines an integrated delivery system?

An organization providing all levels of care from acute hospitals to outpatient services.