RHIT STUDY GUIDE!! WHITE
BOARD NOTES
Utilization Review.-Process of determining whether the medical service provided to a specific Medicare or Medicaid
patient is necessary.
Daily inpatient census-official count of inpatients present at midnight, which is calculated each day Also included are
any patients who were admitted and discharged the same day
Vocabulary standards-provide consistent descriptions of medical terms for an individual's condition in the health
record
Custodian Records-When records for evidence is involved at the trial, the records custodian is called a witness by
one party or other to testify as the authenticity of a record as evidence. The records custodian verifies that it contains
information about the individual.
flowchart-a graphic tool that uses standard symbols to visually display detailed information, including time and
distance, of the sequential flow of work of an individual or a product as it progresses through a process
fish bone chart-a performance improvement tool used to identify or classify the root causes of a problem or condition
and to display the root causes graphically; also called the cause and effect diagram
Aggregated Data-Data that has been extracted from individual health records and combined to form deidentified
information about groups of patients that can be compared.
Overlay-Mistakenly assigned another persons health record number.
Overlap-When a patient has more than one health record number at different locations within an enterprise.
Duplicate Record-2 or more medical record numbers.
Security-To control/protect access of health information and records.
ROI Turnaround Time-Time between receipt of request and when the request is sent to the requester 30 days on site,
60 days off site
Qualitative Analysis-Reviewing a record and ensuring that standards are being met. HIM professionals can review
legibility, timeliness of documentation, use of approved abbreviations and other documentation standards.
Concurrent Review-Ongoing review while patient is in facility. From admission to discharge.
Retrospective Review-Review after patient has been discharged.
, Prospective Review-Review that takes place prior to elective procedures and missions.
Licensure-Organizations are the legal authority from the authorities to carry on certain activities that require
permission. Before healthcare organizations can provide services, they usually must obtain licensure by government
entities such as the state or county in which they are located.
Conditions of Participation-Administrative and operational guidelines under which facilities are allowed to take part in
the Medicare and Medicaid programs.
The Joint Commission TJC-Industry leader in the area of healthcare provider organization accreditation. Also a non-
for-profit organization accredits and certifies more than 20,000 healthcare organizations.
Privacy-The right of a patient to control the disclosure of PHI.
Confidentiality-Legal and ethical concept that requires healthcare providers to protect records and personal/private
information. Responsibility to use, disclose or release information.
Meaningful Use, Stage 3-Using certified EHR technology to improvise quality safety, efficiency, and reduce health
disparities. Engage patients and family, improve care coordination and population and public health
Registration- Admission, Discharge, Transfer R-ADT-Tracks Patient
Uniform Hospital Discharge Data Set UHDDS-hospital inpatients acute care -UB04 is a form used for this data set
Uniform Ambulatory Care Data Set UACDS-Collects data specific to ambulatory care
Healthcare Effectiveness Data and Information Set HEDIS-Designed to collect administrative, claims, and health
record review data.
Outcome and Assessment Information Set OASIS-Home healthcare data set
Data Elements for Emergency Department Systems DEEDS-Emergency Room
Minimum Data Set-Long Term Care Setting
Essential Medical Data Set EMDS-Emergency Care Setting
Data Mapping-Allows for connections between two systems.
Data Warehousing-Process of collecting data from sources within an organization for decision making purposes.
Single database that helps locate data that exists in multiple databases.
Metadata-Data that describes other data.
Case Mix Index-The average relative weight of all cases treated a facility or by a given physician. This is calculated
by dividing the sum of the weights of DRGS for patients discharged by the total number of patients discharged.
National Patient Safety Goals-Goals issued by Joint Commission to improve patient safety in healthcare
organizations nationwide.
False Claims Act-Penalties to those who knowingly submit fraudulent claims to Government for payment.
Chargemaster-List of charges for the healthcare services and supplies at an organization.
Line Graph-Shows continuous data/trends over time.
Histogram-Represents the frequency distribution of numerical data. Like a bar graph but continuous distributed in
categories
BOARD NOTES
Utilization Review.-Process of determining whether the medical service provided to a specific Medicare or Medicaid
patient is necessary.
Daily inpatient census-official count of inpatients present at midnight, which is calculated each day Also included are
any patients who were admitted and discharged the same day
Vocabulary standards-provide consistent descriptions of medical terms for an individual's condition in the health
record
Custodian Records-When records for evidence is involved at the trial, the records custodian is called a witness by
one party or other to testify as the authenticity of a record as evidence. The records custodian verifies that it contains
information about the individual.
flowchart-a graphic tool that uses standard symbols to visually display detailed information, including time and
distance, of the sequential flow of work of an individual or a product as it progresses through a process
fish bone chart-a performance improvement tool used to identify or classify the root causes of a problem or condition
and to display the root causes graphically; also called the cause and effect diagram
Aggregated Data-Data that has been extracted from individual health records and combined to form deidentified
information about groups of patients that can be compared.
Overlay-Mistakenly assigned another persons health record number.
Overlap-When a patient has more than one health record number at different locations within an enterprise.
Duplicate Record-2 or more medical record numbers.
Security-To control/protect access of health information and records.
ROI Turnaround Time-Time between receipt of request and when the request is sent to the requester 30 days on site,
60 days off site
Qualitative Analysis-Reviewing a record and ensuring that standards are being met. HIM professionals can review
legibility, timeliness of documentation, use of approved abbreviations and other documentation standards.
Concurrent Review-Ongoing review while patient is in facility. From admission to discharge.
Retrospective Review-Review after patient has been discharged.
, Prospective Review-Review that takes place prior to elective procedures and missions.
Licensure-Organizations are the legal authority from the authorities to carry on certain activities that require
permission. Before healthcare organizations can provide services, they usually must obtain licensure by government
entities such as the state or county in which they are located.
Conditions of Participation-Administrative and operational guidelines under which facilities are allowed to take part in
the Medicare and Medicaid programs.
The Joint Commission TJC-Industry leader in the area of healthcare provider organization accreditation. Also a non-
for-profit organization accredits and certifies more than 20,000 healthcare organizations.
Privacy-The right of a patient to control the disclosure of PHI.
Confidentiality-Legal and ethical concept that requires healthcare providers to protect records and personal/private
information. Responsibility to use, disclose or release information.
Meaningful Use, Stage 3-Using certified EHR technology to improvise quality safety, efficiency, and reduce health
disparities. Engage patients and family, improve care coordination and population and public health
Registration- Admission, Discharge, Transfer R-ADT-Tracks Patient
Uniform Hospital Discharge Data Set UHDDS-hospital inpatients acute care -UB04 is a form used for this data set
Uniform Ambulatory Care Data Set UACDS-Collects data specific to ambulatory care
Healthcare Effectiveness Data and Information Set HEDIS-Designed to collect administrative, claims, and health
record review data.
Outcome and Assessment Information Set OASIS-Home healthcare data set
Data Elements for Emergency Department Systems DEEDS-Emergency Room
Minimum Data Set-Long Term Care Setting
Essential Medical Data Set EMDS-Emergency Care Setting
Data Mapping-Allows for connections between two systems.
Data Warehousing-Process of collecting data from sources within an organization for decision making purposes.
Single database that helps locate data that exists in multiple databases.
Metadata-Data that describes other data.
Case Mix Index-The average relative weight of all cases treated a facility or by a given physician. This is calculated
by dividing the sum of the weights of DRGS for patients discharged by the total number of patients discharged.
National Patient Safety Goals-Goals issued by Joint Commission to improve patient safety in healthcare
organizations nationwide.
False Claims Act-Penalties to those who knowingly submit fraudulent claims to Government for payment.
Chargemaster-List of charges for the healthcare services and supplies at an organization.
Line Graph-Shows continuous data/trends over time.
Histogram-Represents the frequency distribution of numerical data. Like a bar graph but continuous distributed in
categories
