Foundations in Healthcare Data Management C810 Study Review 2025

Do-Not-Resuscitate order (DNR) - Correct Answer-Specifies an individual's wish not to receive treatment (specifically, cardiopulmonary resuscitation or CPR), directing healthcare providers to refrain from performing the otherwise standing order of CPR should the individual experience cardiac or respiratory arrest, and is most often used by the elderly or chronically ill Advanced Directives - Correct Answer-A special type of written consent that communicates an individual's wishes to be treated or not to be treated should the individual become incapacitated and unable to communicate on his or her own behalf Incident report - Correct Answer-A tool staff can use to report unusual incidents to administration. Depending on the state, an incident report may or may not be protected by statute or regulation. It may also be protected per attorney-client privilege. However, this protection can be superseded if the court determines the information is necessary to a plaintiff's case. Although the facts regarding the incident and the resolution should be documented in the clinical record, the incident report itself is not part of the health record and should never be placed in the record nor referred to in the record. Informed consent - Correct Answer-Ensures the patient has a basic understanding of his or her diagnosis; the nature of the treatment or procedure along with the risks, benefits, and alternatives (to include opting out of treatment); and individuals who will perform the treatment or procedure Metadata - Correct Answer-Electronic data about data that include information not previously available in paper documents, such as time stamps that show when and by whom a document or entry was created, accessed, or changed Consultation - Correct Answer-the act of seeking assistance from another physician(s) or health care professional(s) for diagnostic studies, therapeutic interventions, or other services that may benefit the patient. opinions of physicians with specialty training beyond general board certification such as oncologists, cardiologists, or dermatologists. Discharge summary - Correct Answer-Also called the clinical resume, provides details about the patient's stay while in the facility, is the foundation for future treatment, and is prepared when the patient is discharged or transferred to another facility or when the patient dies Durable power of attorney - Correct Answer-A document in which an adult—while competent—designates another person (proxy) to make healthcare decisions consistent with the individual's wishes on the individual's behalf if he or she is unable History and Physical - includes history of present illness and review of systems - Correct Answer-The history and physical form includes both information about what has led up to the current medical issue and the practitioner's investigation into what the problem actually is. The history is a summary of the patient's illness from his or her point of view. Its purpose is to allow the patient or his or her authorized representative to give the practitioner as much background information about the patient's illness as possible. The physical examination is a comprehensive assessment of the patient's physical condition through examination and inspection of the patient's body by the practitioner. The practitioner usually tailors the physical examination to symptoms described in the patient's history and begins an assessment. The end of the physical examination should include the impression, which is a list of the patient's problems based on the information obtained Hybrid record - Correct Answer-A patient health record that exists in a paper-based and an electronic format Joint Commission - Correct Answer-The successor organization to the American College of Surgeons (ACS) in the area of standardization that assumed responsibility for the accreditation process in 1952 as a joint effort of the ACS, American College of Physicians, American Medical Association, and the American Hospital Association; was initially responsible for the accreditation of hospitals and has since expanded its accreditation process to home health, long-term care, and other types of healthcare facilities Master Patient Index (MPI) - Correct Answer-A permanent database including patient-identifiable data for every patient ever admitted to or treated by the facility Medication Administration Record (MAR) - Correct Answer-A record that is maintained by nursing staff for all patients and includes medications given, time, form of administration, and dosage and strength Patient/member web portal - Correct Answer-A web-based tool or a personal health record offered by the patient's healthcare provider that allows patients to pay their bills online and to securely view all or portions of their provider-based EHR, such as current medical conditions, immunization records, medications, allergies, and test results Personal health record (PHR) - Correct Answer-Tools that individuals can use to collect, track, and share past and current information about their health or the health of someone in their care Problem-oriented medical record - Correct Answer-Developed in the 1970s and is comprised of the problem list, the database (the history and physical examination and initial lab findings), the initial plan (tests, procedures, and other treatments), and progress notes organized so that every member of the healthcare team can easily follow the course of patient treatment Progress notes - includes care, treatment and therapies - Correct Answer-chronological statements about the patient's response to treatment during his or her stay in the facility. Facility procedures and policies must state exactly what categories of personnel are allowed to write or enter information into progress notes. Generally, these personnel include physicians, nurses, physical therapists, occupational therapists, respiratory therapists, social workers, case managers, registered dietitians (RDs), nurse anesthetists, pharmacists, radiologic technologists, speech therapists, and others providing direct treatment or consultation to the patient Record retention - Correct Answer-Involves determining the schedule to be followed to protect and preserve active and inactive records SOAP notes - Correct Answer-a method for recording progress notes. SOAP is an easy acronym that helps providers remember the specific and systematic decision-making process being documented. S = Subjective Findings, patient statements and symptoms O = Objective Findings, laboratory and other test results A = Assessment, based on findings and observations P = Plan, methods and actions to address identified problems Source-oriented health record - Correct Answer-The conventional or traditional method of maintaining paper-based health records in which health records are organized according to the source, or originating, department that rendered the service Data security - Correct Answer-The process in which organizations implement protection measures and tools for safeguarding data and information from unauthorized, accidental, or intentional modification, destruction, or use Disaster recovery plan - Correct Answer-Defines the processes for recovery of data in the event of a disaster Disclosure - Correct Answer-The release, transfer, provision of access to, or divulging in any manner of information outside the entity holding the information Emergency mode operation plan - Correct Answer-Creates processes and procedures to support the continuation of critical business and patient care operations while protecting the security of ePHI in the event of a disaster Health information exchange - Correct Answer-The electronic movement of health-related information among organizations according to nationally recognized standards with the goal to facilitate access to and retrieval of clinical data to provide safer, timelier, efficient, effective, equitable, patient-centered care Health Insurance Portability and Accountability Act (HIPAA) of 199 - Correct Answer-Healthcare regulations that are published in the Federal Register, which carry out the intent of Congress, which initially focused on making it easier for employees to retain health coverage when they changed jobs or their family status changed, and which also address waste, fraud, and abuse in the healthcare system; created a single federal standard electronic claims format for electronic data interchange; and focus on simplifying the administration of health insurance HITECH-HIPAA Omnibus Privacy Act - Correct Answer-The final omnibus rules in 2013 to address many of the HITECH requirements, and strengthens the privacy and security of patient health information, modifies the Breach Notification Rule, strengthens privacy protections for genetic information by prohibiting health plans from using or disclosing such information for underwriting, makes business associates of HIPAA-covered entities liable for compliance, strengthens limitations on the use and disclosure of PHI for marketing, research and fundraising, and allows patients increased restriction rights Individually identifiable health information - Correct Answer-Information that identifies the individual or there is reasonable belief that it can be used to identify the individual, and relates to the individual's past, present, or future physical or mental health or condition; the provision of healthcare to the individual; or the past, present, or future payment for the provision of healthcare to the individual Protected health information (PHI) - Correct Answer-Individually identifiable health information held or transmitted by a covered entity or business associate Ransomware - Correct Answer-malware that prevents or limits the users from gaining access to their system. With ransomware, the hacker blocks the user from accessing systems on the server by encrypting the server and not allowing the user to access it unless a fee is paid through certain online payment methods Risk analysis - Correct Answer-A systemic process for reviewing all systems, applications, and processes to identify potential threats and vulnerabilities, document current controls, and understand the likelihood of the impact Continuity of care record (CCR) - Correct Answer-A core data set of the most relevant administrative, demographic, and clinical information about a patient's healthcare, covering one or more healthcare encounters mHealth or Mobile Health App - application or tool that can be downloaded to a patient's phone and can provide tutorials and self-management videos to help manage diseases. - Correct Answer-The generation, aggregation, and dissemination of health information via mobile and wireless devices Patient portal - Correct Answer-A secure online website that gives patients convenient 24-hour access to personal health information from anywhere with an internet connection Telehealth - Correct Answer-The use of electronic information and telecommunications technologies to support long-distance clinical healthcare, patient and professional health-related education, public health, and health administration Accountability - Correct Answer-The duty of an individual, group, or organization to be answerable for specific activities