RHIA flashcards

32 cards. Read the term and the definition here. The deck at the top of this page is optional.

Information governance

An organization-wide framework of accountabilities, policies, processes, and standards that ensures information is accurate, accessible, secure, and appropriately used and disposed of throughout its lifecycle.

AHIMA IG principles

The eight principles are accountability, transparency, integrity, protection, compliance, availability, retention, and disposition; together they form the basis of AHIMA's information governance framework.

Designated record set

Under HIPAA, a group of records maintained by or for a covered entity that includes medical and billing records used to make decisions about individuals, and to which access and amendment rights apply.

Legal health record

The subset of health information an organization designates as its official business record of care, created at or near the time of care and disclosed on request; it excludes notes not so designated.

Data stewardship

The assignment of accountability for the quality, integrity, and appropriate use of specific data assets to named individuals who manage those assets on behalf of the organization.

Retention schedule

A policy document listing record types and the minimum period each must be kept, based on statutes of limitation, licensure, accreditation, and federal or state requirements, plus destruction methods.

Master patient index

A database that assigns a unique identifier to each patient and links all encounters and records; its accuracy depends on consistent registration and duplicate-detection processes.

Minimum necessary standard

Requires covered entities to limit uses, disclosures, and requests for PHI to the least amount reasonably needed for the purpose; it does not apply to treatment disclosures or authorized disclosures.

Authorization core elements

A valid HIPAA authorization must describe the PHI, who may disclose and receive it, the purpose, an expiration date or event, the individual's signature and date, and revocation and redisclosure statements.

Breach notification deadline

Covered entities must notify affected individuals without unreasonable delay and no later than 60 days after discovery, with HHS notified concurrently when 500 or more individuals are affected.

Accounting of disclosures

Individuals may request a listing of disclosures of PHI made without authorization during the six years before the request, excluding disclosures for treatment, payment, and health care operations.

Right of access timeline

A covered entity must provide requested PHI, or act on a denial, within 30 days of the request and may take one 30-day extension with written notice of the reason.

Psychotherapy notes

Notes recorded by a mental health professional documenting or analyzing the contents of a counseling session; they require a separate, specific authorization for disclosure and are excluded from the general medical record.

42 CFR Part 2

Federal regulations protecting records of substance use disorder treatment in federally assisted programs; they generally require written patient consent for disclosure and prohibit redisclosure without consent.

Sensitivity

The proportion of people who truly have a condition and are correctly identified by a test; calculated as true positives divided by true positives plus false negatives.

Positive predictive value

The probability that a person with a positive test result actually has the condition; calculated as true positives divided by true positives plus false positives.

Incidence rate

The number of new cases of a disease occurring in a defined population during a specified period, divided by the population at risk and usually multiplied by a constant such as 1,000.

Data warehouse

A centralized repository that integrates data copied from multiple source systems, is organized for query and analysis, and typically stores historical, subject-oriented, nonvolatile data.

HL7 FHIR

Fast Healthcare Interoperability Resources is an HL7 standard that uses web-based application programming interfaces and modular resources to exchange health data among systems.

Ratio level of measurement

The highest measurement scale, with equal intervals and a true zero, permitting multiplication and division; examples include weight, length, age in years, and blood pressure.

Case mix index

The sum of the relative weights of all DRGs for a hospital's discharges divided by the total number of discharges; a higher index suggests patients with greater resource intensity.

Days in accounts receivable

Total accounts receivable divided by average daily charges, indicating the average number of days needed to collect outstanding balances; lower values generally reflect faster collection.

Clean claim rate

The number of claims accepted on first submission without edits, rejections, or denials divided by the total number of claims submitted during the period.

MS-DRG

Medicare Severity Diagnosis Related Group is the inpatient prospective payment classification that assigns stays to groups based on principal diagnosis, procedures, complications, and comorbidities.

Charge description master

The hospital's master file of billable items and services with their charges, revenue codes, and CPT or HCPCS codes; it must be maintained to keep charges accurate and compliant.

Net collection rate

Payments received divided by charges minus contractual allowances, expressed as a percentage; it measures how much of the collectible expected reimbursement is actually collected.

Transformational leadership

A style in which leaders inspire and motivate staff through a shared vision, individualized consideration, intellectual stimulation, and idealized influence, producing commitment beyond simple reward exchange.

Herzberg two-factor theory

Hygiene factors such as pay and working conditions prevent dissatisfaction but do not motivate; motivators such as achievement, recognition, and responsibility produce satisfaction and motivation.

Tuckman team stages

The five predictable stages of team development: forming, when members orient; storming, when conflict arises; norming, when roles and norms settle; performing, when the team is productive; and adjourning.

FTE calculation

One full-time equivalent equals 2,080 paid hours per year, or 40 hours per week for 52 weeks; part-time and PRN hours are summed and divided by 2,080 to determine total FTEs.

Root cause analysis

A structured, retrospective method for investigating a sentinel event or serious adverse outcome to identify underlying system failures and design preventive actions, often using a multidisciplinary team.

SWOT analysis

A strategic planning tool that identifies internal strengths and weaknesses and external opportunities and threats facing an organization before goals and strategies are set.