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What is a characteristic of ICD-6? - ANSWER -The first version of ICD used for
both death classification and disease indexing
What was the first ICD revision for which an alternate was made due to
disagreements? - ANSWER -The United States developed its own version of ICD-
8 based on disagreements over the circulatory section.
Which characteristic of ICD-10-PCS represents a difference from ICD-9-CM? -
ANSWER -No diagnostic information is included.
American Health Information Management Association (AHIMA) - ANSWER -a
professional organization for health information management (HIM) professionals
American Hospital Association (AHA) - ANSWER -Non profit group or alliance
of member hospitals and health care organizations that promote the interests of
hospitals. It is an advocacy group for health care organizations, particularly
hospitals
World Health Organization (WHO) - ANSWER -A group within the United
Nations responsible for human health, including combating the spread of infectious
diseases and health issues related to natural disasters.
History of Present Illness (HPI) - ANSWER -eight categories that constitute a
chronological description of an illness.
History of Present Illness (HPI) eight categories - ANSWER -How long have you
had the sore throat? (duration)
What part of your throat hurts? (location)
Is the pain continuous? Does it become better or worse? (timing)
, How does it compare to other sore throats you have had? (severity)
Do you also have other symptoms? (associated signs and symptoms)
What are you doing when it hurts? (context)
How would you describe the pain? (quality)
What have you done to obtain relief? Did it work? (modifying factors)
Common Diagnosis coding process errors - ANSWER -Illegible physician
handwriting
Illogical physician diagnosis documentation
Lack of physician documentation
Transcription errors by typist or voice-recognition systems
Content of the rest of the patient's medical record does not support the diagnosis
documented
Lack of specificity
Hybrid Record - ANSWER -A combination of paper and electronic records; a
health record that includes both paper and electronic elements
Integrated health record - ANSWER -A system of health record organization in
which all the paper forms are arranged in strict chronological order and mixed with
forms created by different departments
The Joint Commission - ANSWER -an independent organization that accredits
healthcare organizations in the United States based on performance standards