RHIT STUDY GUIDE WHITE BOARD NOTES
WITH COMPLETE SOLUTIONS
Utilization Review. - ANS-Process of determining whether the medical service
provided to a specific Medicare or Medicaid patient is necessary.
Daily inpatient census - ANS-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 - ANS-provide consistent descriptions of medical terms for an
individual's condition in the health record
Custodian Records - ANS-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 - ANS-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 - ANS-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 - ANS-Data that has been extracted from individual health records
and combined to form deidentified information about groups of patients that can be
compared.
Overlay - ANS-Mistakenly assigned another persons health record number.
Overlap - ANS-When a patient has more than one health record number at different
locations within an enterprise.
Duplicate Record - ANS-2 or more medical record numbers.
Security - ANS-To control/protect access of health information and records.
ROI Turnaround Time - ANS-Time between receipt of request and when the request
is sent to the requester 30 days on site, 60 days off site
Qualitative Analysis - ANS-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 - ANS-Ongoing review while patient is in facility. From
admission to discharge.
Retrospective Review - ANS-Review after patient has been discharged.
Prospective Review - ANS-Review that takes place prior to elective procedures and
missions.
Licensure - ANS-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 - ANS-Administrative and operational guidelines under
which facilities are allowed to take part in the Medicare and Medicaid programs.
The Joint Commission TJC - ANS-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 - ANS-The right of a patient to control the disclosure of PHI.
Confidentiality - ANS-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 - ANS-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 - ANS-Tracks Patient
Uniform Hospital Discharge Data Set UHDDS - ANS-hospital inpatients acute care -
UB04 is a form used for this data set
Uniform Ambulatory Care Data Set UACDS - ANS-Collects data specific to
ambulatory care
Healthcare Effectiveness Data and Information Set HEDIS - ANS-Designed to collect
administrative, claims, and health record review data.
Outcome and Assessment Information Set OASIS - ANS-Home healthcare data set
Data Elements for Emergency Department Systems DEEDS - ANS-Emergency Room
Minimum Data Set - ANS-Long Term Care Setting
WITH COMPLETE SOLUTIONS
Utilization Review. - ANS-Process of determining whether the medical service
provided to a specific Medicare or Medicaid patient is necessary.
Daily inpatient census - ANS-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 - ANS-provide consistent descriptions of medical terms for an
individual's condition in the health record
Custodian Records - ANS-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 - ANS-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 - ANS-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 - ANS-Data that has been extracted from individual health records
and combined to form deidentified information about groups of patients that can be
compared.
Overlay - ANS-Mistakenly assigned another persons health record number.
Overlap - ANS-When a patient has more than one health record number at different
locations within an enterprise.
Duplicate Record - ANS-2 or more medical record numbers.
Security - ANS-To control/protect access of health information and records.
ROI Turnaround Time - ANS-Time between receipt of request and when the request
is sent to the requester 30 days on site, 60 days off site
Qualitative Analysis - ANS-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 - ANS-Ongoing review while patient is in facility. From
admission to discharge.
Retrospective Review - ANS-Review after patient has been discharged.
Prospective Review - ANS-Review that takes place prior to elective procedures and
missions.
Licensure - ANS-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 - ANS-Administrative and operational guidelines under
which facilities are allowed to take part in the Medicare and Medicaid programs.
The Joint Commission TJC - ANS-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 - ANS-The right of a patient to control the disclosure of PHI.
Confidentiality - ANS-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 - ANS-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 - ANS-Tracks Patient
Uniform Hospital Discharge Data Set UHDDS - ANS-hospital inpatients acute care -
UB04 is a form used for this data set
Uniform Ambulatory Care Data Set UACDS - ANS-Collects data specific to
ambulatory care
Healthcare Effectiveness Data and Information Set HEDIS - ANS-Designed to collect
administrative, claims, and health record review data.
Outcome and Assessment Information Set OASIS - ANS-Home healthcare data set
Data Elements for Emergency Department Systems DEEDS - ANS-Emergency Room
Minimum Data Set - ANS-Long Term Care Setting
