RHIT STUDY GUIDE!! WHITE BOARD NOTES| WITH 100% VERIFIED SOLUTIONS

RHIT STUDY GUIDE!! WHITE BOARD NOTES| WITH 100% VERIFIED SOLUTIONS Disambiguated Data- - ANSWER -A challenge in extracting meaningful data from unstructured text. Clinical notes often contain terms that have more than one meaning. Example: Cold- a disease or body temperature/ Discharge- body fluid or leaving hospital. Revenue Cycle- Front End- - ANSWER -Patient Registration Revenue Cycle Middle- - ANSWER -The documentation of the encounter in the health record, charge capture & coding. Revenue Cycle Back End- - ANSWER -Claims transmission, and accounts receivable. Complete Worked Hours- - ANSWER -Total work output - defective work = complete worked hours OR Completed Work / Hours worked to produce total work output OIG Workplan- - ANSWER -Sets forth various projects including OIG audits and evaluations that are underway or planned to be addressed during the fiscal year ARRA- American Recovery and Reinvestment Act. - ANSWER -Major health information technology law that provides stimulus funds to the US economy in the midst of a major economic downturn. HITECH Health Information Technology for Economic and Clinical Health- - ANSWER -created by ARRA- Allocates funds for implementation of a nationwide health information exchange and implementation electronic health records. Alphabetic Filing System- - ANSWER -Filed alphabetically by patients last name. Straight Numeric- - ANSWER -Filed based directly by the record number in numeric order. Terminal- Digit filing- - ANSWER -Filed by the last two digits terminal digits then the middle two secondary unit then first two tertiary units. Centralized Unit Filing- - ANSWER -The patients encounters are filed in a single location. Alphanumeric Filing System- - ANSWER -First two letters of patients lastname followed by a uniquw numeric identifier. Ex. SA1234 Roll Microfilm- - ANSWER -Images stored on a long roll of film, major problem is that patient encounters can be stored on multiple rolls which can make retrieval difficult. Jacket Microfilm- - ANSWER -Microfilm is cut and inserted into 4x6 inch jackets with sleeves. Microfiche- - ANSWER -Copy of the jacket microfilm. Used to be sent out of the HIM Department instead of using the original Jacket Microfilm. Outguide- - ANSWER -Paper-based health record system to track the location of records removed. Record Reconciliation- - ANSWER -Making sure that all the records have been received by the HIM department after patient has been discharged. CMS- Federal Agency within the US department of Health and Human Services. - - ANSWER -Oversight of Medicare program and state governments. Accreditation- - ANSWER -Voluntary Conditions of Coverage- - ANSWER -Ensures patient quality, safety and improvement of clinical outcomes. Statute- - ANSWER -Piece of legislation written and approved by state/federal legislature, signed to law. Legal Health Record- - ANSWER -Defined by each organizations Documentation that supports revenue pursued by payers Documentation used for legal testimony Expressed Consent- - ANSWER -Consent given by their words or in writing. Implied Consent- Inferred by patients action like when patient sticks out arm for blood pressure Authorization- - ANSWER -Covered Entity may not use or disclose protected health information without consent, also a document required under Privacy Rule or HIPAA. EMTALA- - ANSWER -Emergency Medical Treatment and Active Labor Act- Determines if an emergency condition exists. Long Term Care- - ANSWER -Skilled Nursing Care, Subacute Care facilities, nursing facilities nursing homes, assisted living. Care plan format is called Resident Assessment Instrument RAI- based on Minimum Data Set MDS Patient Assessment Instrument PAI- - ANSWER -Completed shortly after admission and discharges Rehab Facilities are accredited through CARF - ANSWER -Commission on Accreditation of Rehabilitation Facilities Source Oriented Health Record- - ANSWER -Record is organized by source. Example: All nursing notes together.