Administrative vs Clinical Data Flashcards

Vocabulary practice flashcards generated from lecture material covering medical record concepts, data definitions, face sheet standards, consents, advance directives, and clinical documentation.

Data

A single fact or measurement.

Information

Data that has been combined, interpreted, and analyzed for a specific purpose.

Data Set

Recommended data elements with uniform definitions.

Data Collection Requirements

Processes that need to be consistent, reliable, and valid.

TPO

Treatment, Payment, Healthcare Operations.

Administrative Data

Information in a patient record that includes demographic and financial details.

Clinical Data

Documentation in a patient record related to diagnoses and treatments.

Demographic Data

Data used to identify an individual, such as name, address, gender, age, and Social Security number.

Social Security Number (SSN)

The most widely discussed and debated unique patient identifier, and the number one way identity theft occurs.

Financial Data

Data used to complete claim forms submitted to third-party payers (TPP), including occupations, employers, insurance companies, member IDs, and group policy numbers.

Face Sheet

Also known as the 'identification sheet' of the medical record, containing demographic, financial, and admitting clinical data collected by admitting personnel.

R-ADT

Registration-Admission, Discharge, Transfer; an electronic system used for collecting admission, demographic, and financial data.

UHDDS

Uniform Hospital Discharge Data Set; a core data set of 20 data elements required for inpatient hospital discharges.

UACDS

Uniform Ambulatory Care Data Set; a uniform healthcare data set used for outpatient record collection.

Face Sheet Completion Standard

According to TJC and CMS standards, the Face Sheet must be completed within 30 days of discharge.

Consent for Admission

A mandatory form covering Treatment, Payment, Healthcare Operations (TPO) required in every patient record by CMS, TJC, and AOA.

Consent for ROI

Consent for Release of Information, required when a patient, insurance company, or outside provider requests a copy of the health record.

Consent for Surgery

A consent form required specifically in records of patients who undergo a surgical procedure in an inpatient or outpatient setting.

Implied Consent

Non-verbal consent assumed for treatment, primarily utilized in emergency situations when a patient is unable to give agreement.

Expressed Consent

Written or verbal agreement given prior to any healthcare treatment or testing.

Advance Directives (AD)

A general term for written advance healthcare treatment directives, including living wills, DPOA HC, and DNR/DNI orders.

Living Will

A patient-written document specifying which death-prolonging procedures to withhold or withdraw, signed and dated by the author and witnessed by non-family.

DPOA HC

Durable Power of Attorney for Healthcare; a notarized document allowing an individual to name an agent to make medical decisions if they become incapacitated.

DNR/DNI

Do Not Resuscitate / Do Not Intubate; instructions directing medical staff not to perform CPR, chest compressions, life-saving medications, or emergency breathing.

Patient Self-Determination Act of 1990 (PSDA)

A federal law requiring healthcare facilities to notify patients aged 18 and older of their right to place an advance directive in their record.

Patient Property Form

An administrative form listing items brought to the facility (e.g., dentures, hearing aids) signed by staff and patient to assist in returning left-behind items.

Certificate of Birth

An NCHS-designed form completed by the HIM department containing newborn and parent information, filed with the state usually within 10 days of birth.

Certificate of Death

An NCHS-designed form completed by the HIM department containing decedent information and cause of death, filed with the state within 5 days of death.