medical history

chief complaint, history of present illness, past medical history, personal history, family history, and a review of systems

physical examination adds

objective data to the subjective data provided by the patient

The physical examination begins with

the physician's objective assessment of the patient's general condition

integrated progress notes

document progress notes sequentially on the same form

point-of-care documentation

data entry that occurs at the point and location of service

POMR

problem-oriented record

CARF

Commission on Accreditation of Rehabilitation Facilities

CARF is

an independent accrediting agency for rehabilitation facilities.

Palliative care

is most likely to be provided at a hospice

Validity

the accuracy of data

reliability

consistency of data

Timeliness

data being available within a time frame helpful to the user

precision

data values that are just large enough to support the application of the process.

COP requires a consultation report

on patients who are not a good surgical risk

Pharmacy consults

are required for elderly patients who typically take multiple medications

patient's certification period

60-day time frame for home health services

accession number 13-0001/00

"13" represents the year that the patient first entered the database

"0001" indicates that this was the first case entered that year

"00" indicates that this patient has only one known neoplasm

EDMS

electronic data management system

CPOE

computerized provider order entry system

National Practitioner Data Bank

With the passage of the Health Care Quality Improvement Act of 1986, the NPDB was established. Hospitals are required to query this before granting clinical privileges to physicians.

discharge order

Although many patient health records may feasibly contain all of the orders listed, only the ____________ is required to document the formal release of a patient from the facility.

left against medical advice

Absence of a discharge order would indicate that the patient __________________ and this event should be thoroughly documented as well.

Conditions of Participation

CMS publishes both proposed and final rules for the _______________ for hospitals in the daily Federal Register.

Disclosure of Student Immunizations to Schools

The ___________________ provision of the final HITECH Omnibus Rule permits a covered entity to disclose proof of immunization to a school (where state law requires it prior to admitting a student) without written authorization of the parent. An agreement must still be obtained and documented, but no signature by the parent is required.

Data reliability

implies that data are consistent no matter how many times the same data are collected and entered into the system

Accessibility

implies that data are available to authorized people when and where needed

Legibility

implies data that are readable

Completeness

implies that all required data are present in the information system

Data comprehensiveness

refers specifically to the presence of all required data elements

The antepartum record should include a _____________________ on each OB patient visit with particular attention to menstrual and reproductive history.

comprehensive history and physical exam

cognitive patterns

represents a data item collected more typically in long-term care settings and required in the MDS

Principal diagnosis, procedures and data, and personal identification represent items collected on ______________ according to UHDDS requirements.

Medicare inpatients

Quantitative analysis

involves checking for the presence or absence of necessary reports and/or signatures

Qualitative analysis

involves checking documentation consistency, such as comparing a patient's pharmacy drug profile with the medication administration record

hospital census

a primary data source for health care statistics

number index

identifies new health record numbers and the patients to whom they were assigned

physicians' index

identifies all patients treated by each doctor

patient index

links each patient treated in a facility with the health number under which the clinical information can be located

disease index

major source of case findings for cancer registry programs

Data Elements for Emergency Departments (DEEDS)

recommended data set for hospital-based emergency departments

Uniform Hospital Discharge Data Set (UHDDS)

required data set for acute care hospitals

Minimum Data Set (MDS)

required data set for long-term care facilities

ORYX

five core measures are implemented to improve safety and quality of health care

Federal Register

a daily government newspaper for publishing proposed and final rules of federal agencies

Data accuracy

denotes that data are correct values

Data comprehensiveness

denotes that all data items are included

Data granularity

denotes that the attributes and values of data should be defined at the correct level of detail

Data precision

denotes that data values should be just large enough to support the application of process.

Time and means of arrival is required on

ED records only

Evidence of known advance directive is required on

inpatient records only

Problem list is required on

ambulatory records by the third visit

the primary concern in forms design

The needs of the user

"Objective symptoms observed by the physician" refers to the

Physical Exam

"Past and current activities, such as smoking and drinking habits" refers to the

Social History

"A chronological description of patient's present condition from time of onset to present" refers to the

History of Present Illness

"review of systems" differs from "physical exam"

"subjective symptoms that the patient may have forgotten to mention or that may have seemed unimportant.”

medical staff bylaws

reflect general principles and policies of the medical staff

the rules and regulations

outline the details for implementing the general principles and policies of the medical staff, including the process and time frames for completing records, and the penalties for failure to comply.

"Adverse effects and contraindications of drugs utilized during hospitalization"

deals with issues directly linked to quality of care reviews

"quality of care through the use of pre-established criteria"

deals with issues directly linked to quality of care reviews

"Potentially compensable events"

deals with risk management

"The overall quality of documentation in the record"

points to a review aimed at evaluating the quality of documentation in the health record`

Type I recommendation

Institutions are given a _________________________ when 2% of delinquent records are due to missing history and physicals or operative reports.

RAC program (recovery audit contractors)

mandated to find and correct improper Medicare payments paid to health care providers participating in the Medicare reimbursement program

OIG

Office of Inspector General

MEDPAR

Medicare Provider Analysis and Review

QIO

Quality Improvement Organization

The Master Patient Index (MPI)

The MPI cross-references the patient name and medical record number

Disease Index

the disease index is a listing in diagnostic code number order

Physician Index

The physician index is a listing of cases in order by physician name or number

recommended for aisles between file units when using stationary open-shelf files

36 inches

Medicare's Conditions of Participation for Hospitals requires that patient health records be retained for at least __________ unless a longer period is required by state or local laws

5 years

The Food and Drug Administration require research records pertaining to cancer patients be maintained for

30 years

A quality control measure that should be established for the filing, storage, and retrieval of health records includes criteria for the

inclusion of late reports

If there is more than one patient with the identical last name, first name, and middle initial, the master patient index entries are then arranged according to the

date of birth

A 16-year-old female delivers a stillborn infant in Mercy Hospital. The clinical documentation on the stillborn infant would be filed in

the mother's record

It is recommended that all but ______________________ should be permanently retained in some format, even when the remainder of the health record is destroyed.

dates of admission, discharge, and encounters

Conditions of participation (COP)

Regulations governing providers of services to Medicare beneficiaries that require providers to develop, implement, and maintain an organization wide quality and performance improvement program.

Unless state or federal laws require longer time periods, AHIMA recommends that patient health information for minors be retained for

at least to the age of majority plus statute of limitations

database management system

an application that would be MOST effective for utilizing various related files that include clinical and financial data to generate reports such as MS-DRG case mix reports

roll microfilm

a microform type that is the least expensive to prepare and results in the greatest storage density

Jacket microfilm

the microform preferred if the records must be unitized and color-coded for filing purposes

The American College of Surgeons mandates a ___________ follow-up rate for all cancer cases to meet approval requirements as a cancer program.

90%

Information brokering

the business of buying and selling information as a commodity

interfaced system

a large collection of clinical information systems and hospital information systems that are designed to share data without human or technical intervention

ORYX measurement requirements are intended to support

Joint Commission-accredited organizations in their quality improvement efforts

Meaningful use

using certified electronic health record (EHR) technology to:

Improve quality

safety

efficiency

reduce health disparities

engage patients and family

Improve care coordination

population and public health

Maintain privacy and security of patient health information.

Continuity of care

an ideal in which health care is provided for a person in a coordinated manner and without disruption despite involvement of different practitioners in different care settings

Active patient

a patient who has had a visit to any location within the previous three years

Problem list

a list of illnesses, injuries, and other factors that affect the health of an individual patient, usually identifying the time of occurrence or identification and resolution

Significant medical diagnosis/condition

any nontransient problem that is significant enough to be relevant to the health of the patient going forward, as well as diagnoses that are confirmed and relevant to future care.

Significant operative and invasive procedures

any operative or invasive procedure that is significant enough to be relevant to the health of the patient going forward

Healthcare Effectiveness Data and Information Set (HEDIS)

a tool used by more than 90 % of America's health plans to measure performance on important dimensions of care and service. HEDIS consists of 71 measures across 8 domains of care.

Diagnosis-Related Group (DRG)

a statistical system of classifying any inpatient stay into groups for the purposes of payment

divides possible diagnoses into more than 20 major body systems and subdivides them into almost 500 groups for the purpose of Medicare reimbursement.

The DRG classification system

limiting charge

the maximum amount that most non-participating providers are allowed to charge for services to a Medicare beneficiary on an unassigned basis

Stark law

a limitation on certain physician referrals

Centralized Filing

a filing system in which the records for several people or units are located in one, central location

Decentralized filing system

each department has its own records close at hand

executive information system (EIS) or

executive support system (ESS)

a type of management information system that facilitates and supports senior executive information and decision-making needs

SQL (Structured Query Language)

a tool that may be used to retrieve collected patient satisfaction data from the database to improve clinical services

HTML (Hyper Text Markup Language)

a markup language for describing web documents (web pages)

Extensible Markup Language (XML)

a markup language that defines a set of rules for encoding documents in a format which is both human-readable and machine-readable

a prerequisite in the implementation of an electronic health record, and a process that would facilitate automatic indexing

Redesigning forms to include bar codes

structured interview

uses a set of standard questions that are asked to all job applicants to gather comparative data.

unstructured interview

uses general questions from which other questions are developed over the course of the conversation

stress interview

uses specific questions to determine how the interviewee responds under pressure.

Questions in this type of interview set up specific scenarios and ask the interviewee how he or she would handle the situation.

Due process

provides for fair treatment through a hearing procedure

the chief criterion for determining record inactivity

The amount of space available for storage of newer records

MDS data are reported directly to

Centers for Medicare and Medicaid Services

Reassignment

involves moving a document from one episode of care to a different episode of care within the same patient record

information collected for a transplant registry

patient demographic information, diagnosis codes, functional status, and histocompatibility information

clinical vocabulary

A list or collection of clinical words or phrases with their meanings

medical decision making

is measured by risk of complications, number of diagnoses or management options, and the amount and complexity of data reviewed.

excision

cutting out or off, without replacing a portion of a body part

Healthcare Cost and Utilization Project (HCUP)

consists of a set of databases that include data on inpatients whose care is paid for by third-party payers

record-over-record method

The method of calculating errors in a coding audit that allows for benchmarking with other hospitals, and permits the reviewer to track errors by case type

Aggregate data

statistics for your facility that include average length of stay (ALOS) and discharge data by DRG

Modifier -53

the procedure was discontinued

antepartum care includes

routine chemical urinalysis, initial and subsequent history, and physical examination

logic-based encoder

An encoder that prompts the coder to answer a series of questions and choices based on the documentation in the medical record

International Classification on Functioning, Disability, and Health (ICF) system

a classification of health and health-related domains that describe body functions and structures, domains of activities and participation, and environmental factors that interact with all of these components

CPT Category III codes

includes codes to describe emerging technologies

The Joint Commission requires a comprehensive H & P to be completed and available

within 24 hours, or sooner if surgery is to be performed

The Joint Commission permits an interval H & P examination

when a patient is admitted within 30 days for the same condition

The Joint Commission requires that a developmental age evaluation and educational needs assessment be included in the medical history and review of systems when the patient is

a child or adolescent

differential diagnosis

a list of alternatives if several diagnoses potentially fit the patient’s clinical presentation

Ascension number

a unique identifier that identifies specimens in the laboratory

Stare Desis

“Let the decision stand.”

Cancer staging

the process of determining how much cancer is in the body and where it is located

Res Ipsa Loquitur

“The thing speaks for itself.”

Results reporting

applications designed to retrieve diagnostic test and treatment results from feeder systems

clinical data repository

collects, organizes, and analyzes all institutional business and clinical data that have been summarized and aggregated for that purpose

Clinical Terms Version 3

(previously known as Read Codes Version 3)

a computer based nomenclature and classification.

Nomenclature

the devising or choosing of names for things, especially in a science or other discipline

Specialist Lexicon

a database of lexicographic information for use in natural language processing

Alternative Billing Codes (ABC codes)

five-digit HIPAA compliant alpha codes to describe services, remedies and/or supply items provided and/or used during patient visits.

HCPCS Level 1

CPT and is written by the American Medical Association (AMA).

HCPCS Level 2

a standardized coding system that is used primarily to identify products, supplies, and services and is written by CMS.

Clinical vocabulary

a catalog of terms approved for use in the description of clinical signs and problems, and for the definition of diagnoses and diseases.

Registries

Birth Defects

Cancer

Death

Diabetes

Immunization

Implant

Organ transplant

three components to CPT radiology codes

professional, technical, and global components

professional component

describes the services of a physician who supervises the taking of an x-ray film and the interpretation with report of the results

technical component

describes the services of the person who uses the equipment, the film, and other supplies

global component

describes the combination of both professional and technical components

modifier -26

radiologist only the professional component of the procedure

Digoxin

used for maintenance therapy in congestive heart failure, atrial fibrillation, atrial flutter, and paroxysmal atrial tachycardia

Ibuprofen

an anti-inflammatory drug

Oxytocin

used to initiate or improve uterine contractions at term

haloperidol

used to manage psychotic disorders

Unified Medical Language System (UMLS)

a project sponsored by the National Library of Medicine

A cancer program is surveyed for approval by

the Commission on Cancer of the American College of Surgeons

abstracting

review patient record and enter the required elements into a database

If no bilateral code is provided and the condition is bilateral

assign separate codes for both the left and right side

reference date for a cancer registry

the date when data collection began

The most common type of registry in hospitals of all sizes

cancer registry

the database/registry you will utilize most often

The National Practitioner Data Bank (NPDB)

One of the major functions of the cancer registry

to ensure that patients receive regular and continued observation and management

Patient follow-up in cancer registry should be continued

for the life of the patient

the primary concern when designing systems

The needs of the end user

Histocompatibility information is collected and maintained in the

organ transplant registry

When a provider, knowingly or unknowingly, uses practices that are inconsistent with accepted medical practice and that directly or indirectly result in unnecessary costs to the Medicare program, this is called

abuse

APR-DRGs

DRG system that classifies the non-Medicare population, such as HIV patients, neonates, and pediatric patients

ANSI ASC X12N 837

electronic format for health care claims transactions

hard coding

HCPCS/CPT codes that appear in the hospital's chargemaster and will be included automatically on the patient's bill

CMS adjusts the Medicare Severity DRGs and the reimbursement rates every fiscal year beginning

October 1

sent to patients (beneficiaries) as their EOB

Medicare Summary Notice (MSN)

Medicare summary notice

a statement sent to the patient to show how much the provider billed, how much Medicare reimbursed the provider, and what the patient must pay the provider

Accounts Receivable (A/R)

cases that have not yet been paid

balance billing

the patient is financially liable for charges in excess of the Medicare Fee Schedule, up to a limit

HCPCS code

a uniform system of identifying procedures, services, or supplies

IPPS Transfer rule

hospitals are paid a graduated per diem rate for each day of the patient’s stay, not to exceed the prospective payment DRG rate

Hold harmless

financial protections to ensure that certain types of facilities recoup all of their losses due to the differences in their APC payments and the pre-APC payments.

item/service description

a narrative name of the services provided

limiting charge

15% above Medicare's approved payment amount for doctors who do NOT accept assignment

denied claim

When the third-party payer refuses to grant payment to the provider

TRICARE

a health care program for active members of the military and other qualified family members

UB-04

the claim form used by hospitals

CMS-1500

the claim form used by physicians and other noninstitutional providers and suppliers

CMS-1491

the claim form used by ambulance services

Rehabilitation hospitals are reimbursed under the

Inpatient Rehabilitation Prospective Payment System (IRF PPS)

Long-term care hospitals are reimbursed under the

Long-Term Care Hospital Prospective Payment System (LTCH PPS)

Skilled nursing facilities are reimbursed under the

Skilled Nursing Facility Prospective Payment System (SNF PPS)

Cancer hospitals can apply for and receive waivers from ______________________________ and are therefore excluded from the inpatient prospective payment system (MS-DRGs).

the Centers for Medicare and Medicaid Services (CMS)

the 72-hour rule

This rule requires that outpatient preadmission services that are provided by a hospital up to three calendar days prior to a patient's inpatient admission be covered by the IPPS MS-DRG payment for diagnostic services and therapeutic (or nondiagnostic) services whereby the inpatient principal diagnosis code (ICD-10-CM) exactly matches the code used for preadmission services.

Advance Beneficiary Notice (ABN)

a document signed by the patient indicating whether he/she wants to receive services that Medicare probably will not pay for

global payment

A lump-sum payment distributed among the physicians who performed the procedure or interpreted its results and the health care facility that provided equipment, supplies, and technical support

medical necessity

the service or procedure is reasonable and necessary for the diagnosis or treatment of illness or injury consistent with generally accepted standards of care

Never events or Sentinel events

errors in medical care that are clearly identifiable, preventable, and serious in their consequences for patients

prospective payment system

based on resource utilization groups (RUGs) is used for reimbursement to skilled nursing facilities for patients with Medicare

Medicaid

a joint federal and state program that provides health care coverage to low-income populations and certain aged and disabled individuals

Cost accounting

a method that attributes a dollar figure to every input required to provide a service

explanation of benefits

a statement sent by a health insurance company to covered individuals explaining what medical treatments and/or services were paid for on their behalf

3 main components of a healthcare organization

1. The governance
2. The management
3. The employed staff

Resource Utilization Groups (RUG)

MDS assessment forms are completed for all residents in certified nursing homes, regardless of source of payment for the individual resident.

Communities of Practice (CoP)

groups of people who share a concern or a passion for something they do and learn how to do it better as they interact regularly

Accession

an ordered test or group of tests on a particular specimen which has been formally received by a lab or other health care service and has received an accession number.

To input the demographics for a particular patient’s analysis into an information system; to log or document receiving a specimen in the lab.

Coding audit methods

1. Select charts randomly
2. Don’t review your own charts
3. Use the same rules as the auditors
4. Keep coding audits results professional and educational
5. Work at correcting errors

CPT codes Category I

Procedures that are consistent with contemporary medical practice and are widely performed.

CPT codes Category II

Supplementary tracking codes that can be used for performance measures

CPT codes Category III

Temporary codes for emerging technology, services and procedures

Accreditation

the act of granting approval to a healthcare organization

Licensure

a states act of granting a healthcare organization or an individual healthcare practitioner permission to provide services of a defined scope in a limited geographical are

Certification

grants approval for a healthcare organization to provide services to a specific group of beneficiaries

Compliance

the process of meeting a prescribed set of standards or regulations to maintain active accreditation, licensure, or certification status

Quality Improvement Organizations (QIO)

review patient records to ensure that the care provided by practitioners meets the federal standards for medical necessity, level of care, and quality of care.

Measures of success data

data specifically developed for the organizations compliance with Joint Commission standards

Quality Indicator Survey

a two-staged survey process designed to produce a standardized resident-centered, outcome-oriented quality review

Information governance

an organization-wide framework for managing information throughout its lifecycle and supporting the organization’s strategy, operations, and regulatory, legal and environmental requirements

The Triple Aim

Care, health, and cost

End user

The person who actually uses a particular product

Under ASC PPSs, bilateral procedures are reimbursed at

150% of the payment rate for their group

LCD (Local Coverage Determinations)

is published by the Medicare Administrative Contractors (MACs) to describe when and under what circumstances Medicare will cover a service.

grouper

A computer software program that assigns appropriate MS-DRGs according to the information provided for each episode of care

revenue code

A three-digit code that describes a classification of a product or service provided to a patient

capitation reimbursement

method that issues lump-sum payments to providers to compensate them for all the health care services delivered to a patient for a specific illness and/or over a specific period of time.

Medicare Part B

offers voluntary, supplemental medical insurance to help pay for physician's services, outpatient hospital services, medical services, and medical-surgical supplies not covered by the hospitalization plan

State Medicaid programs are required to offer medical assistance for individuals with

qualified financial need.

electronic data interchange (EDI)

computer-to-computer transfer of data between providers and third-party payers in a data format agreed upon by both parties

APCs

prospective payment system used to reimburse hospitals for Medicare hospital outpatients

In calculating the fee for a physician's reimbursement, the three relative value units are each multiplied by the

geographic practice cost indices

The three relative value units are

physician work, practice expense, and malpractice expense

Payment Status Indicator (PSI) "T" means

if a patient has more than one CPT code with this PSI, the procedure with the highest weight will be paid at 100% and all others will be reduced or discounted and paid at 50%.

Charge capturing

the gathering of charge documents from all departments within the facility that have provided services to patients.

The purpose is to make certain that all charges are coded and entered into the billing system.

Alteration

Modifying the natural anatomic structure of a body part without affecting the function of the body part

Bypass

Altering the route of passage of the contents of a tubular body part

Change

Taking out or off a device from a body part and putting back an identical or similar device in or on the same body part without cutting or puncturing the skin or mucous membrane

Control

Stopping, or attempting to stop, post-procedural bleeding

Creation

Making a new genital structure that does not physically take the place of a body part

Destruction

Physical eradication of all or a portion of a body part by the direct use of energy, force, or a destructive agent

Detachment

Cutting off all or part of the upper or lower extremities

Dilation

Expanding an orifice or the lumen of a tubular body part

Division

Cutting into a body part without draining fluids and/or gases from the body part in order to separate or transect a body part

Drainage

Taking out/letting out fluids and/or gases from a body part

Excision

Cutting out or off, without replacement, a portion of a body part

Extirpation

Taking or cutting out solid matter from a body part

Extraction

Pulling or stripping out or off all or a portion of a body part by the use of force

Fragmentation

Breaking solid matter in a body part into pieces

Fusion

Joining together portions of an articular body part rendering the articular body part immobile

Insertion

Putting in a non-biological device that monitors, assists, performs, or prevents a physiological function but does not physically take the place of a body part

Inspection

Visually and/or manually exploring a body part

Map

Locating the route of passage of electrical impulses and/or locating functional areas in a body part

Occlusion

Completely closing an orifice or the lumen of a tubular body part

Reattachment

Putting back in or on all or a portion of a separated body part to its normal location or other suitable location

Release

Freeing a body part from an abnormal physical constraint by cutting or by use of force

Removal

Taking out or off a device from a body part

Repair

Restoring, to the extent possible, a body part to its normal anatomic structure and function

Replacement

Putting in or on biological or synthetic material that physically takes the place and/or function of all or a portion of a body part

Reposition

Moving all or a portion of a body part to its normal location or other suitable location

Resection

Cutting out or off, without replacement, all of a body part

Supplement

Putting in or on biologic or synthetic material that physically reinforces and/or augments the function of a portion of a body part

Restriction

Partially closing an orifice or the lumen of a tubular body part

Revision

Correcting, to the extent possible, a malfunctioning or displaced device

Transfer

Moving, without taking out, all or a portion of a body part to another location to take over the function of all or a portion of a body part

Transplantation

Putting in or on all or a portion of a living body part taken from another individual or animal to physically take the place and/or function of all or a portion of a similar body part

open approach

Cutting through the skin or mucous membrane and any other body layers necessary to expose the site of the procedure

Percutaneous approach

Entry, by puncture or minor incision, of instrumentation through the skin or mucous membrane and any other body layers necessary to reach the site of procedure

Percutaneous endoscopic approach

Entry, by puncture or minor incision, of instrumentation through the skin or mucous membrane and any other body layers necessary to reach and visualize the site of the procedure

Via Natural or Artificial Opening approach

Entry of instrumentation through a natural or artificial external opening to reach the site of the procedure

Via Natural or Artificial Opening Endoscopic approach

Entry of instrumentation through a natural or artificial external opening to reach and visualize the site of the procedure

Via Natural or Artificial Opening with Percutaneous Endoscopic Assistance approach

Entry of instrumentation through a natural or artificial opening and entry, by puncture or minor incision, of instrumentation through the skin or mucous membrane and any other body layers necessary to aid in the performance of the procedure

External approach

procedures performed directly on the skin or mucous membrane and procedures performed indirectly by the application of external force through the skin or mucous membrane

PCS #1

Section

PCS #2

Body system

PCS #3

Root operation

PCS #4

Body part

PCS #5

Approach

PCS #6

Device

PCS #7

Qualifier

PCS placeholder

"X"

Root Operations That Take Out Solids, Fluids, Gases from a Body Part

Drainage

Extirpation

Fragmentation

Root Operations Involving Cutting or Separation Only

Division

Release

Root Operations That Put in or Put Back or Move Some or All of a Body Part

Transplantation

Reattachment

Transfer

Reposition

Impetigo

can be either spread through autoinoculation or caused by Streptococcus pyogenes

Trigeminal neuralgia

a condition that involves the fifth cranial nerve, also known as "tic douloureux," causes intense pain in the eye and forehead; lower lip, the section of the cheek closest to the ear and the outer segment of the tongue; or the upper lip, nose, and cheek

The most common type of vaginitis

both yeast and protozoan

carcinoma

Cancer derived from epithelial tissue is classified as

Carpal tunnel syndrome is caused by

entrapment of the medial nerve

laparoscopic gastric banding

The least invasive restrictive gastric surgery

A disease of the inner ear with fluid disruption in the semicircular canal that causes vertigo

both labyrinthitis and Meniere's disease

lithium carbonate

drug commonly used to treat bipolar mood swings

Parkinson disease

"pill-rolling" tremor of the hand is a characteristic symptom

The first stage of alcoholic liver disease is

fatty liver

Increased glucose metabolism is an effect of

insulin

the presence of Reed-Sternberg cells

is indicative of Hodgkin's disease

Obesity, cigarette smoking, and age are all conditions which predispose risk associated with

essential hypertension

Chronic bronchitis, emphysema, and smoking fall under the category of

COPD

Portal hypertension can contribute to

ascites, dilation of the blood vessels lining the intestinal tract and esophageal varices

Corneal "FB"

foreign body

Removal FB left cornea (root operation)

extirpation

Mitral valve annuloplasty using ring, open (root operation)

Supplement

Amputation first left toe (root operation)

Detachment

Application of skin graft to the nose status post excision malignant neoplasm

Replacement

In the Medical Surgical Section, the second character position represents

Body System

In the Medical Surgical Section, the third character position represents

Root Operation

Uterine dilation and curettage (root operation)

Extraction

In the Medical Surgical Section, the fourth character position represents?

Body Part

Gastric lap band for treatment of morbid obesity (root operation)

Restriction

a procedure used to help prevent miscarriage

Cervical cerclage

What is the optimal level of total cholesterol in the blood for adults?

< 200 mg/dL

digoxin

A common cardiac glycoside medication that increases the force of the cardiac contraction without increasing the oxygen consumption, thereby increasing the cardiac output is typically given to patients with heart failure

helper cell

a T cell that influences or controls the differentiation or activity of other cells of the immune system

cytotoxic T cells

A cytotoxic T cell is a T lymphocyte (a type of white blood cell) that kills cancer cells, cells that are infected (particularly with viruses), or cells that are damaged in other ways

plasma cells

cells that produce antibodies

A cells

Alpha cells (more commonly alpha-cells or α-cells) are endocrine cellsin the pancreatic islets of the pancreas. They make up to 20% of the human islet cells synthesizing and secreting the peptide hormone glucagon, which elevates the glucose levels in the blood.

helper B cells

B cells, also known as B lymphocytes, are a type of white blood cell of the lymphocyte subtype. They function in the humoral immunity component of the adaptive immune system by secreting antibodies. Additionally, B cells present antigen (they are also classified as professional antigen-presenting cells (APCs)) and secrete cytokines.

memory cells

a long-lived lymphocyte capable of responding to a particular antigen on its reintroduction, long after the exposure that prompted its production

mast cell

a cell filled with basophil granules, found in numbers in connective tissue and releasing histamine and other substances during inflammatory and allergic reactions

a chronic, systemic disease whose initial infection is in the lungs

tuberculosis

autoimmunity

the body’s immune system reverses itself and attacks the organs and tissues

5 layers of the epidermis

stratum basale

stratum spinosum

stratum granulosum

stratum lucidum

stratum corneum

hemoglobin determination

A hematology laboratory test that evaluates the oxygen-carrying capacity of blood

ejaculatory duct

A tube that conveys sperm from the seminal vesicle to the urethra

Increasing peristalsis of the intestines, increasing salivation, and a slowing heart rate are examples of

parasympathetic nervous system

Sympathetic nervous system

A part of the nervous system that serves to accelerate the heart rate, constrict blood vessels, and raise blood pressure

autonomic nervous system

the part of the nervous system responsible for control of the bodily functions not consciously directed, such as breathing, the heartbeat, and digestive processes

prothrombin time (PT) test evaluates

coagulation of the blood

Graves' disease

is an autoimmune disease

SARS (severe acute respiratory syndrome)

Coronavirus

Methicillin-resistant Staphylococcus aureus (MRSA)

is caused by a type of staph bacteria that's become resistant to many of the antibiotics used to treat ordinary staph infections

Novel H1N1 influenza

A virus responsible for a flu pandemic in 2009 that was originally referred to as "swine flu" because many of the genes in this new virus were very similar to influenza viruses that normally occur in pigs in North America

MDR-TB

a severe, chronic, two-phased, bacterial respiratory infection that has become increasingly difficult to treat because many antibiotics are no longer effective against it

Coronary artery bypass grafting (CABG)

improves the coronary blood flow by building an alternate route for the blood to bypass the blockage by inserting a portion of another blood vessel, typically the saphenous vein

Percutaneous transluminal coronary angioplasty (PTCA)

a minimally invasive procedure to open up blocked coronary arteries, allowing blood to circulate unobstructed to the heart muscle

Carotid endarterectomy (CEA)

a surgical procedure used to reduce the risk of stroke, by correcting stenosis (narrowing) in the common carotid artery or internal carotid artery

Endarterectomy

the removal of material on the inside (end(o)-) of an artery

protozoa

The organism transmitted by a mosquito bite that causes malaria

rickets

Softening of the bone in children

carcinoembryonic antigen (CEA) test

measures the amount of this protein that may appear in the blood of some people who have certain kinds of cancers

Acute myocardial infarction (AMI)

heart attack

Rocky Mountain spotted fever

The most common rickettsial disease in the United States

synergistic effect

The interaction of two drugs working together to where each simultaneously helps the other achieve an effect that neither could produce alone

the usual treatment for Helicobacter pylori

antibiotics

Gardasil is a quadrivalent vaccine. What is the definition of quadrivalent?

It prevents infection from the four most prevalent types of HPV that cause cervical cancer.

A treatment for sensorineural hearing loss is

cochlear implants

A distinguishing characteristic of a toxic goiter is

thyroid hyperfunction

AST (SGOT)

liver function test

Rheumatoid arthritis typically affects

the knees and small joints of the hands and feet

The etiology of aplastic anemia is

bone marrow failure

the organ that has endocrine and exocrine functions

pancreas

the QRS wave

the electronic stimulation of the ventricles

P wave

atrial depolarization, which results in atrial contraction

PR interval

the period that extends from the beginning of the P wave (the onset of atrial depolarization) until the beginning of the QRS complex (the onset of ventriculardepolarization)

QT interval

a measure of the time between the start of the Q wave and the end of the T wave in the heart's electrical cycle

ST segment

connects the QRS complex and the T wave

T wave

represents the repolarization (or recovery) of the ventricles

A common vitamin taken by pregnant women to substantially reduce the occurrence of neural tube defects, such as spina bifida, in a developing fetus

folic acid

A sweat test was done on a patient with the following symptoms: frequent respiratory infections, chronic cough, and foul-smelling bloody stools. What diseases is probably suspected?

cystic fibrosis

Huntington's disease

a hereditary disease of the cerebral cortex that includes progressive muscle spasticity and mental impairment leading to dementia

Bell's palsy

aralysis of the facial nerve, causing muscular weakness in one side of the face

Amyotrophic lateral sclerosis (ALS)

sometimes called Lou Gehrig's disease, is a rapidly progressive, invariably fatal neurological disease that attacks the nerve cells (neurons) responsible for controlling voluntary muscles

Guillain–Barré syndrome (GBS)

a rapid-onset muscle weakness caused by the immune system damaging the peripheral nervous system

pernicious anemia

a deficiency in the production of red blood cells through a lack of vitamin B12

Autoimmune hemolytic anemia

occurs when antibodies directed against the person's own red blood cells (RBCs) cause them to burst (lyse), leading to insufficient plasma concentration.

aplastic anemia

deficiency of all types of blood cells caused by failure of bone marrow development

homeostasis

The state of balance or normality that the human body continuously tries to attain

Diastole occurs when

the ventricles fill

systole occurs when

the heart contracts and pumps out blood to the rest of the body

hemophilia

the ability of the blood to clot is severely reduced

thalassemia

any of a group of hereditary hemolytic diseases caused by faulty hemoglobin synthesis

iron-deficiency anemia

Too few healthy red blood cells due to too little iron in the body.

superior and inferior rectus

the set of muscles that controls the movement of the eye up and down

ventricular fibrillation

a lethal arrhythmia

What term would be applied to a comparison of the number of female patients to the number of male
patients who were discharged from MS-DRG YYY?

Ratio

Suppose that there are six males in a class of twenty students. What term could be used to
describe the comparison?

Proportion

What descriptive statistics is calculated by applying this equation: (x/y) x 10n?

Ratio
Proportion
Rate

In May, 270 women were admitted to the Obstetrics service. Of these, 263 women delivered; 33
deliveries were by C-section. What is the denominator for calculating the C-section rate?

263

Suppose that you want to display the number of deaths due to breast cancer for the years 1990
through 1999. What graphic technique would you choose?

Line graph

Suppose that you want to display the average length of stay by gender and service for the month of
August. What graphic technique would you choose?

Line graph

If you are interested in displaying the parts of a whole in graphic form, what graphic technique
would you use?

Pie chart

In a frequency distribution, the lowest value is 5 and the highest value is 20. What is the range?

15

I just realized that we may be misleading administration with the data we provided them.
Which of the following might we have done?

Failed to adjust the baseline

I work for AHRQ. I have to choose the next project for AHRQ. Which of the
following would I choose?

A study to determine how the EHR improves patient safety and quality of care

Which rate describes the number of new cases of an illness for a specific time period?

Incidence rate

Which term is used to describe the number of inpatients present at the census- taking time each
day plus the number of inpatients who were both admitted and discharged after the census-taking time
the previous day?

Daily inpatient census

Which unit of measure is used to indicate the services received by one inpatient in a 24-hour
period?

Inpatient service day

Which rate is used to compare the number of inpatient deaths to the total number of inpatient
deaths and discharges?

Gross hospital death rate

Suppose a patient who underwent orthopedic surgery acquired Klebsiella pneumonia while
hospitalized. How could this illness be described?

As a postoperative infection
As a hospital-acquired infection
As a community acquired infection

Which term is used to describe the number of calendar days that a patient is hospitalized?

Length of stay

What rate is used to indicate the percentage of the hospital’s beds occupied by inpatients for a
given time period?

Percentage of occupancy

Inpatient bed occupancy rate

Which rate compares the number of autopsies performed on hospital inpatients to the total
number of inpatient deaths for the same period of time?

Gross autopsy rate

Suppose that five patients stayed in the hospital for a total of 27 days. Which term would be used
to describe the result of the calculation 27 ÷ 5?

Average length of stay

The probability of death among diagnosed cases of a specific disease

case fatality rate

Data elements that are considered protected under the HIPAA Privacy Rule

Patient telephone number
Patient name
Medical record number
Zip code

AHRQ

Agency for Healthcare Research and Quality

IDDM

insulin-dependent diabetes mellitus (AKA: diabetes 1 and juvenile diabetes)

CXR

Chest X-Ray

DEXA scan

bone density scan

APR DRG

All Patients Refined Diagnosis Related Groups

All Patients Refined Diagnosis Related Groups (APR DRG)

A classification system that classifies patients according to their reason of admission, severity of illness and risk of modality - The patient characteristics used in the definition of the DRGs are limited to.

POA indicator is assigned to

principal and secondary diagnoses

PPS

Prospective Payment System

IRF PPS

Inpatient Rehabilitation Facility Prospective Payment System

IRF-PAI

Inpatient Rehabilitation Facility Patient Assessment Instrument

EFT

Electronic Funds Transfer

NCD

National Coverage Determinations

HAVEN software

Home Assessment Validation Entry was designed for the stand-alone home health agency as a data entry tool to encode and edit the OASIS data.

RBRVS

Resource-based relative value scale

Resource-based relative value scale (RBRVS)

a schema used to determine how much money medical providers should be paid. It is partially used by Medicare in the United States and by nearly all health maintenance organizations (HMOs).

Hashimoto's disease

an autoimmune disease, a disorder in which the immune system turns against the body's own tissues, the immune system attacks the thyroid

Goodpasture's syndrome

antiglomerular basement antibody disease, or anti-GBM disease) is a rare autoimmune disease in which antibodies attack the basement membrane in lungs and kidneys, leading to bleeding from the lungs and kidney failure

myasthenia gravis

autoimmune diseases affects tissues of the nervous system. A weakness and rapid fatigue of muscles under voluntary control

Most carbon dioxide is carried in the

red blood cells

the average timeframe in which all patients with new, previously untreated TB must have daily antibiotic therapy

6-9 months

The process of cancer development, from exposure through the cellular changes of hyperplasia to neoplasia

carcinogenesis

a lethal arrhythmia

ventricular fibrillation

Treponema pallidum

syphilis

guaiac smear test

Fecal occult blood test

prostatic-specific antigen test

is a protein produced by cells of the prostate gland, measures the level of PSA in a man's blood.

The hypothalamus, thalamus, and pituitary gland are all parts of the

limbic system

A serum potassium level of 2.8 would indicate

diabetic ketoacidosis

Addison's disease

A disorder in which the adrenal glands don't produce enough hormones. Specifically, the adrenal glands produce insufficient amounts of the hormone cortisol and sometimes aldosterone, too.

hypokalemia

deficiency of potassium in the bloodstream

endocrine gland secretes melatonin, which controls the circadian rhythm of an individual

pineal

Islets ofLangerhans

beta cells of the pancreas, they make insulin and amylin

adrenal medulla secretes

Cortisol, Aldosterone, and Androgenic steroids (androgen hormones)

alpha cells of the pancreas

secrete glucagon

delta cells

secrete somatostatin

gamma cells

secrete pancreatic polypeptide

pathogenesis

The progress of a disease

etiology

the cause a disease or condition

Most of the digestion of food and absorption of nutrients occur in the

small intestine

Sex-linked genetic diseases

involve a defect on a chromosome

hereditary hemochromatosis (HH)

is a genetic disease that alters the body's ability to regulate iron absorption

cystic fibrosis

An inherited life-threatening disorder that damages the lungs and digestive system.

Tay-Sachs disease

A rare, inherited disorder that destroys nerve cells in the brain and spinal cord. A fatty substance in the brain destroys nerve cells.

phenylketonuria

A birth defect that causes an amino acid called phenylalanine to build up in the body.

Newborns are screened for PKU.

Untreated PKU can lead to brain damage, mental retardation, behavioral symptoms, or seizures.

Treatment includes a strict diet with limited protein.

Decubitus ulcer stage 1

sores are not open wounds. The skin may be painful, but it has no breaks or tears.

Decubitus ulcer stage 2

the skin breaks open, wears away, or forms an ulcer, which is usually tender and painful. The sore expands into deeper layers of the skin. It can look like a scrape (abrasion), blister, or a shallow crater in the skin.

Decubitus ulcer stage 3

the sore gets worse and extends into the tissue beneath the skin, forming a small crater. Fat may show in the sore, but not muscle, tendon, or bone.

Decubitus ulcer stage 4

the pressure sore is very deep, reaching into muscle and bone and causing extensive damage. Damage to deeper tissues, tendons, and joints may occur.

the upper respiratory tract

The nose, mouth, sinuses, pharynx, and larynx

the lower respiratory tract

the windpipe (trachea) and within the lungs, the bronchi, bronchioles, and alveoli.

upper gastrointestinal tract

the esophagus, stomach and duodenum

lower gastrointestinal tract

the anus, rectum, colon, and cecum

von willebrand disease

A bleeding disorder caused by low levels of clotting protein in the blood

osteomyelitis

Inflammation of bone caused by infection, generally in the legs, arm, or spine

Adenoma

a benign tumor formed from glandular structures in epithelial tissue

Fibroma

a benign, tumor-like growth made up mostly of fibrous or connective tissue

Nevi

A common pigmented skin lesion, usually developing during adulthood (mole)

Lipoma

A fatty lump most often situated between the skin and underlying muscle layer

Adenocarcinoma

a malignant tumor formed from glandular structures in epithelial tissue

Liposarcoma

a malignancy of fat cells

Osteosarcoma

A type of bone cancer that begins in the cells that form bones

Primary site

Original site or point of origin

Secondary site

Site or sites where malignancy has spread (metastases)

Benign

noncancerous

Malignant

cancerous

In situ

in original place

CANCER DEVELOPMENT STAGES

NORMAL CELLS -- HYPERPLASIA -- DYSPLASIA CANCER IN SITU -- INVASIVE CANCER

Uncertain behavior

when the neoplasm behavior cannot be determined pathologically

Unspecified behavior

when the behavior is not stated

When coding surgical removal of a neoplasm followed by adjunct chemotherapy or radiation treatment during the same episode of care, the code for the neoplasm should be assigned as

principal or first-listed diagnosis

leukoplakia

Thickened, white patches inside the mouth

Leukocytosis

an increase in the total number of WBCs due to any cause

lymphocytosis

an increase in the number of lymphocytes in the blood

lymphocyte

a form of small leukocyte (white blood cell) with a single round nucleus, occurring especially in the lymphatic system that are of fundamental importance in the immune system

Neutrophils

help fight infection by ingesting microorganisms and releasing enzymes that kill the microorganisms

Neutropenia

is an abnormally low level of neutrophils

monocytes

a large phagocytic white blood cell that fights off bacteria, viruses and fungi

eosinophils

a type of white blood cell that play an important role in the body's response to allergic reactions, asthma, and infection with parasites

multiple myeloma

A cancer of plasma cells. The disease can damage the bones, immune system, kidneys, and red blood cell count.

Plasma cell neoplasms

diseases in which there are too many plasma cells, or myeloma cells, that are unable to do their usual work in the bone marrow

According to CPT guidelines, when a patient is admitted to the hospital on the same day as an office visit, the office visit is

not billable

chemical pleurodesis

performed to prevent recurrence of pneumothorax or recurrent pleural effusion

decortication

the removal of the outer layer or cortex from a structure, especially the lung, brain, or other organ

trichiasis

ingrowth or introversion of the eyelashes

double-J stent

a soft tube that is placed during surgery. This tube has a curl at both ends designed to prevent the stent from moving down into the bladder or up into the kidney

Cardioversion

medical procedure by which an abnormally fast heart rate (tachycardia) or cardiac arrhythmia is converted to a normal rhythm using electricity or drugs

Huhner test

determination of the number and condition of spermatozoa in mucus aspirated from the canal of the cervix uteri within 2 hours after coitus

meningocele

a protrusion of the meninges through a gap in the spine due to a congenital defect

adrenalectomy

the surgical removal of one or both adrenal glands

TIPS procedure

interventional radiologists use image guidance to make a tunnel through the liver to connect the portal vein (the vein that carries blood from the digestive organs to the liver) to one of the hepatic veins (three veins that carry blood away from the liver back to the heart).

Informed consent

A legally-effective, voluntary agreement that is given by a prospective research participant following comprehension and consideration of all relevant information pertinent to the decision to participate in a study.

Belmont principle of justice

1. Respect for persons
2. Beneficence
3. Justice

The principle of respect

1. Individuals should be treated as autonomous agents

2. Persons with diminished autonomy are entitled to additional protections

Autonomous person

An individual capable of deliberation about personal goals and of acting under the direction of such deliberation

Coercion

influencing an individual's decision about whether or not to do something by using explicit or implied threats (loss of good standing in a job, poor grades, etc.).

Undue influence

An offer of an excessive, unwarranted, inappropriate, or improper reward or other overture in order to obtain compliance

Beneficence

1. Do no harm
2. Maximize possible benefits and minimize possible harms

a concept in research ethics which states that researchers should have the welfare of the research participant as a goal of any clinical trial or other research study. The antonym of this term, maleficence, describes a practice which opposes the welfare of any research participant.

Diminished autonomy

An individual with restricted capability of deliberation about personal goals and of limited ability to act under the direction of their deliberations.

IRB

Institutional Review Board

IRB committees

consist of 5 or more members with varying expertise and diversity that are responsible for reviewing and approving human subjects research activities on behalf of institutions.

data model

often the first step in database design and object-oriented programming as the designers first create a conceptual modelof how data items relate to each other.

data dictionary

a set of information describing the contents, format, and structure of a database and the relationship between its elements, used to control access to and manipulation of the database

DBMS

database management system

database management system (DBMS)

a computer software application that interacts with the user, other applications, and the database itself to capture and analyze data (it is the interface engine that will be needed to manage communication between systems)

data standard

documented agreements on representation, format, and definition for common data

ISDM

industry standard data model

industry standard data model (ISDM)

A data model that is widely applied in some industry, and shared amongst competitors to some degree. They are often defined by standards bodies, database vendors or operating system vendors

decision support system (DSS)

a computer program application that analyzes business data and presents it so that users can make business decisions more easily

clinical decision support system (CDSS)

a health information technology system that is designed to provide physicians and other health professionals with clinical decision support (CDS), that is, assistance with clinical decision-making tasks

knowledge-based system (KBS)

a computer program that reasons and uses a knowledge base to solve complex problems

financial information system

Atype of business software used to input, accumulate, and analyze financial and accounting data. It produces reports such as accounting reports, cash flow statements, and financial statements

One of the ways that an EHR is distinguished from a clinical data repository is that the EHR

has clinical decision support capabilities

foreign key

a field (or collection of fields) in one table that uniquely identifies a row of another table

The foreign key is defined in a second table, but it refers to the _____________________ in the first table.

primary key

request for information (RFI)

a standard business process whose purpose is to collect written information about the capabilities of various suppliers. Normally it follows a format that can be used for comparative purposes

RFI

request for information

risk assessment

a systematic process of evaluating the potential risks that may be involved in a projected activity or undertaking

request for proposal

a solicitation, often made through a bidding process, by an agency or company interested in procurement of a commodity, service or valuable asset, to potential suppliers to submit business proposals

RFP

request for proposal

feasibility study

an assessment of the practicality of a proposed plan or method

project plan

a formal document designed to guide the control and execution of a project

strategic plan

an organization's process of defining its strategy, or direction, and making decisions on allocating its resources to pursue this strategy

vision statement

a declaration of an organization's objectives, ideally based on economic foresight, intended to guide its internal decision-making

front-end speech recognition

that the original dictator's speech is turned into text

back-end speech recognition

a speech recognition system where the staff dictates and then the editing of the dictation is done by editors

keyword spotting

a subfield of speech recognition that deals with the identification of keywords in utterances

SQL

A common language used in data definition and data manipulation

UML

Unified Modeling language

Unified Modeling language (UML)

A standardized modeling language enabling developers to specify, visualize, construct and document artifacts of a software system.

metadata

a set of data that describes and gives information about other data

A function is found in an ambulatory EHR but not in an acute care EHR

registration

eMAR

electronic medication administration record

electronic medication administration record (eMAR)

Automatically track medications from order to administration using assistive technologies

meaningful use

using certified electronic health record (EHR) technology to: Improve quality, safety, efficiency, and reduce health disparities. Engage patients and family. Improve care coordination, and population and public health. Maintain privacy and security of patient health information

This Medicare program requires the use of a certified electronic health record

meaningful use

hybrid network

a type of network topology that uses two or more other network topologies, including bus topology, mesh topology, ring topology, star topology, and tree topology

network protocol

formal standards and policies comprised of rules, procedures and formats that define communication between two or more devices over a network

physical topology

the placement of the various components of a network, including device location and cable installation, while logical topology illustrates how data flows within a network, regardless of its physical design

TCP/IP

Transmission Control Protocol/Internet Protocol

TCP/IP (Transmission Control Protocol/Internet Protocol)

the basic communication language or protocol of the Internet. It can also be used as a communications protocol in a private network (either an intranet or an extranet)

The decision on which system to purchase should be:

quantifiable

agenda

a list of items to be discussed at a formal meeting

data mining

the practice of examining large databases in order to generate new information

interface engine

a term used to refer to a kind of middleware application which is used to transform, route, clone and translate messages

prototyping

Creating a demo of a new system

Legally authorized representative

An individual or judicial or other body authorized under applicable law to consent on behalf of a prospective subject to the subject's participation in the procedure(s) involved in the research

The principle of respect for persons can be broken down into two basic ideas:

1. Individuals should be treated as autonomous agents
2. Persons with diminished autonomy are entitled to additional protections

The three fundamental aspects of informed consent are:

Voluntariness

Comprehension

Disclosure

Voluntariness

Individuals’ decisions about participation in research should not be influenced by anyone involved in conducting the research: “...consent must be freely given or truly voluntary."

Comprehension

Individuals must have the mental or decisional capacity to understand the information presented to them in order to make an informed decision about participation in research.

Minimal risk

The probability and magnitude of harm or discomfort anticipated in the research are not greater in and of themselves than those ordinarily encountered in daily life or during the performance of routine physical or psychological examinations or tests.

Assent

“...affirmative agreement to participate in research. Mere failure to object should not, absent affirmative agreement, be construed as assent.”

OHRP

Office for Human Research Protections (part of HHS)

Two general rules have been articulated as complementary expressions of beneficent actions:

1. Do no harm
2. Maximize possible benefits and minimize possible harms

Risk (in research)

the probability that a certain harm will occur

Types of Risk (in research)

A. Physical

B. Psychological

C. Social

D. Legal

E. Economic

risk-benefit analysis

The proposed research has a favorable ratio of potential benefit to risk.

Therapeutic misconception

The tendency for research participants to: “downplay or ignore the risks posed to their own well-being by participation ... [due to] the participants deeply held and nearly unshakeable conviction that every aspect of their participation in research has been designed for their own individual benefit.”

Equipoise

Substantial scientific uncertainty about which treatments will benefit subjects most, or a lack of consensus in the field that one intervention is superior to another.

Clinical trial

“...a prospective biomedical or behavioral research study of human subjects that is designed to answer specific questions about biomedical or behavioral interventions (drugs, treatments, devices, or new ways of using known drugs, treatments, or devices).”

Privacy

being “free from unsanctioned intrusion.”

Confidentiality

holding secret all information relating to an individual, unless the individual gives consent permitting disclosure.

Anonymized data

Lacking “identifiers or codes that can link a particular sample to an identified specimen or a particular human being.”

Coded data (research)

Identifiers are removed from the data in exchange for codes that correspond to the identifiers, and the identifiers are maintained separately from the rest of the dataset.

Data and Safety Monitoring Plan

Describes protections for research participants and data integrity, and oversight for clinical trials at a level that is commensurate with the risks of participating in the clinical trial and is required by NIH.

client server

a software architecture model consisting of two parts, client systems and server systems, both communicating over a computer network or on the same computer.

operating system

the software that supports a computer's basic functions, such as scheduling tasks, executing applications, and controlling peripherals.

portal

an Internet site providing access or links to other sites

A survey of your patients has found that they want access to test results and the ability to schedule appointments online. What technology should be used to provide these services?

portal

You use an information system to create a letter notifying a requester that your facility does not have any records on file for the individual's records requested. What system are you using?

release of information

Your release of information system has part of the computing on the workstation and part on the file server. What type of technology is being used?

client server

chart locator

keeps track of the location of all records in the health care facility.

chart deficiency

incomplete charts

Your role is to help patients determine where to store their personal health record. What area do you specialize in?

privacy

When calling the HIM Department, you say the word "two" to reach the release of information system. What technology is this?

interactive voice recognition

interactive voice recognition (IVR)

a technology that allows a computer to interact with humans through the use of voice and DTMF tones input via keypad.

voice over Internet protocol

an IP telephony term for a set of facilities used to manage the delivery of voice information over the Internet

migration path

A series of conversion steps that allow an organization to evolve smoothly to newer hardware and software in order to keep pace with changing technology.

integration testing

a software testing methodology used to test individual software components or units of code to verify interaction between various software components and detect interface defects

application testing

a process by which application software developed for hand held mobile devices is tested for its functionality, usability and consistency

acceptance testing

a test conducted to determine if the requirements of a specification or contract are met

volume testing

testing a software application or the product with a certain amount of data

indemnification

secure (someone) against legal responsibility for their actions

force majeure

A common clause in contracts that essentially frees both parties from liability or obligation when an extraordinary event or circumstance beyond the control of the parties, such as a war, strike, riot, crime, or an event described by the legal term act of God (hurricane, flood, earthquake, volcanic eruption, etc.), prevents one or both parties from fulfilling their obligations under the contract.

interface

a shared boundary across which two separate components of a computer system exchange information

network

a telecommunications network which allows computers to exchange data

source code

a text listing of commands to be compiled or assembled into an executable computer program

Clinical Data Repository (CDR) or Clinical Data Warehouse (CDW)

a real time database that consolidates data from a variety of clinicalsources to present a unified view of a single patient.

project scope

the part of project planning that involves determining and documenting a list of specific project goals, deliverables, tasks, costs and deadlines

critical success factors

a management term for an element that is necessary for an organization or project to achieve its mission

scope creep

in project management refers to uncontrolled changes or continuous growth in a project's scope

structured data entry

a data entry method by interacting with pre-defined forms

unstructured data entry

information that either does not have a pre-defined data model or is not organized in a pre-defined manner

What element is most critical in the contract negotiation to ensure use of the software in multiple environments?

license grant