CCMA Lesson 2: Health Records (EMRS) and Healthcare Delivery Systems

Practice flashcards for CCMA Lesson 2 covering medical records, healthcare delivery, HIPAA, and computer systems based on lecture notes.

How is a 'Professional' defined in healthcare?

Someone who is trained in a specific body of language, governed by a code of ethics, and who seeks out and is often required to obtain continued education to keep current and learn new skills.

Who qualifies as a 'Healthcare Provider' authorized to practice in a state?

A Doctor of Medicine or osteopathy, podiatrist, dentist, chiropractor, clinical psychologist, optometrist, nurse practitioner, nurse-midwife, or clinical social worker.

What is the distinction between clinical staff and administrative staff?

Clinical staff is referred to as the back office, while administrative staff is referred to as the front office.

What entity is responsible for establishing a hospital's by-laws and policies?

A governing board, or board of directors.

What is the meaning of the acronym CEO?

Chief Executive Officer

What is the meaning of the acronym CFO?

Chief Financial Officer

What is the meaning of the acronym COO?

Chief Operations Officer

What is the meaning of the acronym CIO?

Chief Information Officer

What is the meaning of the acronym CNO?

Chief Nursing Officer

What is the primary responsibility of the Chief of Staff in a hospital?

Overseeing the hospital's medical staff and all clinical services as well as reporting to the board.

What is a 'Hospitalist'?

A physician employed by the hospital to care for patients only while they are in the hospital; the patient returns to their primary care physician after discharge.

How is 'Diagnosis' defined?

The determination of the source of a medical complaint.

How is 'Treatment' defined?

A course of medical services designed to heal, correct, alleviate or resolve a medical complaint.

Under whose supervision do LPNs or LVNs provide routine patient care?

Under the direct supervision of a Registered Nurse (RN) or a physician.

How many states do not allow Nurse Practitioners (NPs) to prescribe controlled substances?

$5$ states

What is the minimum degree requirement for an Advanced Practice Registered Nurse (APRN)?

A minimum of a master's degree.

What is the role of a Certified Registered Nurse Anesthetist (CRNA)?

To administer anesthesiology during surgery under the supervision of an anesthesiologist.

How long is the intensive medical education typically received by a Physician Assistant (PA)?

$26$ weeks

In a professional credential, what does 'C' typically signify?

Certified

What is the role of a Physical Therapist (PT)?

To help patients regain strength, range of motion, and maximal function in daily activities.

What is the goal of an Occupational Therapist (OT)?

To improve physical abilities with the goal of reducing disability and increasing independent living and skills of daily life.

What types of patients are assessed and treated by a Respiratory Therapist (RT)?

Patients with breathing disorders, stroke, heart failure, asthma, emphysema, or other difficulties breathing.

Technically, what is a medical doctor who specializes in clinical pathology called?

A pathologist

What training and tasks are associated with Phlebotomists?

They are trained in vocational programs or hospitals and draw blood from patients for laboratory testing.

What degree is required for a Pharmacist?

A Doctor of Pharmacy or $Pharm.D.$ degree.

What is the standard education for an Audiologist?

A doctoral degree called an $AuD$, though some states accept a master's degree.

What are the primary roles of a Medical Assistant (MA)?

To perform both administrative and clinical tasks, such as collecting specimens, billing and coding, and assisting with minor surgeries.

What does the term 'non-clinical' refer to in allied health professions?

Occupations that do not involve medical or diagnostic services to the patient, such as IT managers or billing specialists.

What is 'Health Information Management' (HIM)?

Refers to all tasks involved in the collection, storage, retrieval, securing, protecting, and reporting of patient health information.

In the flow of inpatient information, what is 'Chart Abstraction'?

Extracting certain elements from source documents for data entry, including condition, illness, and outcomes.

What is the 'Institute of Medicine' (IOM) call for regarding patient records?

The creation of an electronic patient record designed to support users through accessibility, alerts, and clinical decision support.

What does a 'DRG Coordinator' review in an inpatient facility?

Patient records to ensure correct $ICD-10-CM/PCS$ and $DRG$ (Medicare diagnosis-related groups) codes are assigned.

What is the 'DRG' system?

A system used to classify hospital cases into one of $467$ groups to identify services and products for Medicare reimbursement.

At what point in a transcriptionist's career can they become a Certified Medical Transcriptionist (CMT)?

After $2$ years of experience and passing the certification exam.

What are 'Clinical Vocabularies'?

Standardized codes and terms for recording symptoms, diseases, drugs, and other medical components.

What are the 'Administrative Safeguards' required by HIPAA?

Policies and procedures that manage the conduct of employees, including training and managing logins.

What is the role of a 'Privacy Officer' as required by HIPAA?

Overseeing activities related to the development and maintenance of privacy policies and ensuring adherence to $PHI$ and HIPAA regulations.

What is the primary difference between Ambulatory and Acute care facilities?

Ambulatory (outpatient) care does not require an overnight stay, whereas Acute (inpatient) care requires an overnight stay for one or more days.

What does 'Occupancy' refer to in a healthcare facility?

The percentage of available beds that have been used over a certain period.

What is a 'Bed Count'?

The actual number of beds that a hospital has staffed, equipped, and made available for occupancy for each specific operating day.

What are 'Ancillary Services'?

A broad range of evaluation services, such as radiology and laboratory services.

What is the '72 hour rule' regarding Emergency Department visits and hospital admission?

A billing complication where a patient who visits the emergency department and returns to be admitted within $72$ hours cannot be billed for two different visits.

What is 'Palliative Care' as provided in a hospice?

Care that makes the patient comfortable by easing pain and other discomforts.

What is 'Continuity of Care'?

The coordination among caregivers to treat a patient through communication and movement between departments or facilities.

What is 'Integrated Delivery Systems' (IDS)?

The trend for hospitals and other health entities to merge to consolidate care and share health information along the lifespan continuum.

What is a 'Licensed Bed Count'?

The maximum number of patients a hospital is legally permitted to have at one time, as set by the state.

What is the role of an 'Attending Doctor' during hospital admission?

The doctor assigned to the patient who completes medical history and physicals, and orders tests and medications.

How is 'Reimbursement' defined in healthcare?

The payment made to providers and facilities for healthcare services, supplies, and equipment.

What is a 'Health Insurance Premium'?

A fixed monthly payment made by an individual to an insurance company in exchange for medical coverage.

What is the 'Deductible' in out-of-pocket costs?

The amount paid by the patient before insurance starts covering costs.

What does the acronym HIPAA stand for?

Health Insurance Portability and Accountability Act

What is the mission of the American Medical Association (AMA)?

To promote the art and science of medicine and the improvement of public health.

What is 'HL7' (Health Level Seven)?

An organization of experts collaborating to create standards for the exchange, management, and integration of electronic healthcare information.

What is the 'The Joint Commission'?

An independent, not-for-profit organization that improves healthcare quality by setting optimum standards for patient care.

How many specific types of Electronic Data Interchange (EDI) are standardized under HIPAA?

$10$ types

What standardized code set is used for Diagnosis?

$$ICD-10-CM$$

What standardized code sets are used for Procedures?

$CPT-4$ and $HCPCS$

What is the 'National Provider Identifier' (NPI)?

A unique $10$-digit identification number for healthcare providers.

What are the three pillars of HIPAA Privacy Policies?

Confidentiality, Privacy, and Security.

What are the twelve exceptions to the requirement for patient consent under HIPAA?

Legal mandates, law enforcement, judicial proceedings, public health, threats, victims of abuse, workers' comp, government functions, oversight, death, organ donation, and research.

What does the acronym 'TPO' stand for in health information use?

Treatment, Payment, and Healthcare Operations.

What is the 'Minimum Necessary' standard?

The requirement that providers share only the least amount of information necessary to satisfy a request.

Under HIPAA, how long must disclosure records be retained by a facility?

$6$ years

What are the three layers of protection required by the HIPAA Security Rule?

Administrative, Physical, and Technical Safeguards.

What is the role of the 'CPU' in a computer?

The Central Processing Unit is the main part of the computer that does all data processing or 'thinking.'

What is the difference between RAM and ROM?

$RAM$ is temporary, volatile workspace memory, while $ROM$ contains permanent, non-volatile startup instructions.

What is the smallest unit of data in a database?

A Character

What is a 'Relational Database'?

A database consisting of multiple tables linked through common fields, such as a Patient ID number.

What does 'DICOM' stand for in diagnostic imaging?

Digital Imaging and Communication in Medicine.

What is the difference between a LAN and a WAN?

A $LAN$ (Local Area Network) connects computers in a small, limited area, while a $WAN$ (Wide Area Network) connects computers across long distances or large cities.

Which level of interoperability ensures systems use standardized coding so the receiving system can interpret and use data?

Semantic Interoperability

What is 'Teleradiology'?

The electronic transmission of diagnostic images from one clinical location to another for interpretation by a radiologist.

What is the 'SOAP' format in medical decision making?

Subjective, Objective, Assessment, and Plan.

Which data set is used for reporting inpatient data in acute care hospitals?

$UHDDS$ (Uniform Hospital Discharge Data Set)

How is 'Data Accuracy' defined in data quality?

Data that is correct and reflects what actually happened, such as recording a temperature of $37.2\text{ }^{\circ}C$ exactly.

What is a 'Source-Oriented Record' (SOR)?

A paper record organized strictly by the department of origin, filed in reverse chronological order.

What is 'Terminal Digit Filing'?

A numeric filing system where numbers are read backwards from right to left in pairs, using the final two digits as the primary filing unit.

What is 'Optical Character Recognition' (OCR)?

Technology that scans physical text and converts it into live, digitally recognizable and editable text data.