C810 Foundations in Healthcare Data Management Exam 2025

Constitutional Law laws outlined in federal and state Constitutions common law created by courts that resolve disputes statutory law written law established by federal and state legislatures administrative law branch of law that controls the government agency malfeasance execution of unlawful or improper act misfeasance improper act that results in injury nonfeasance failure to act as a prudent person would in similar circumstances Degrees of Negligence ordinary, gross, criminal Privacy Act of 1974 addresses the right to privacy and was written to give individuals some control over information collected on them by the federal government consent one's permission or agreement to an action general consent permit healthcare providers to perform overall medical care informed consent ensure patient has a basic understanding of their diagnosis, the nature of treatment, and the individuals who are rendering treatment advance directive written consent that communicates a person's wishes to be treated or not when they become incapacitated durable power of attorney document where an adult (while competent) designates another person to make healthcare decisions when they become incompetent or unable to do so Patient Self-Determination Act (PSDA) requires healthcare institutes that bill Medicare and Medicaid for services to provide adult patients with information about the various types of advanced directives Uniform Hospital Discharge Data Set (UHDDS) collects discharge data from hospital inpatient health records; is the standard for collecting Medicare and Medicaid data Uniform Ambulatory Care Data Set (UACDS) A data set developed by the National Committee on Vital and Health Statistics consisting of a minimum set of patient/client-specific data elements to be collected in ambulatory care settings Minimum Data Set (MDS) federally mandated assessment form to collect demographic and clinical data on nursing home residents; must be completed at time of admission and during reassessment periods Outcomes and Assessment Information Set (OASIS) data set to measure outcomes and risk factors of Medicare patients receiving home health; data is used to determine when patient should be discharged and if they need to be transferred Healthcare Effectiveness Data and Information Set (HEDIS) designed to collect administrative, claims, and health record review data; evaluates the success of various treatment plans Data Elements for Emergency Department Systems (DEEDS) used to support the collection of data for hospital-based emergency rooms ORYX An initiative of TJC that implements 5 core measures to improve safety and quality of health care. ATIPCARD acronym for the information governance principles for healthcare accountability a member of senior leadership shall oversee the IG program and delegate program responsibility tranparency an organization's processes and activities should be documented in an open and verifiable manner; documentation shall be available to the organization's workforce integrity information generated by the organization has a reasonable guarantee of authenticity and reliability protection IG program must ensure appropriate levels of protection from breach, corruption, and loss compliance IG shall be constructed to comply with applicable laws and regulations availability organization shall maintain information in a manner that ensures timely, accurate, and efficient retrieval retention an organization shall maintain its information for an appropriate amount of time disposition an organization shall provide secure and appropriate disposition for information no longer required to be maintained patient A ----- signature must be included on a consent form 30 days prior; 24 hours after H&P should be completed no more than ----- to admission or ----- admission unstructured free-text information is ----- data specifying data quality requirements ------- is the best practice for data governance National Practitioner Data Bank (NPDB) A data bank established by the federal government through the 1986 Health Care Quality Improvement Act that contains information on professional review actions taken against physicians and other licensed healthcare practitioners, which healthcare organizations are required to check as part of the credentialing process RACs the CMS external audit program that works to reduce Medicare improper payments TJC A sentinel event must be reported to ------ claim a statement of services submitted by a healthcare provider to a third-party payer fee-for-service (FFS) issue payments to healthcare providers on the basis of the charges assigned to each of the separate services that were performed for the patient