RHIA Study Test with Complete
Solutions
Serial-unit numbering system - Answer-patient is issued a different number for each
admission or encounter for care and records of past episodes of care are brought
forward to be filed under last number used
Source-oriented health record - Answer-system of health record organization in which
information is arranged according to the patient care department that provided the care
Straight numeric filing system - Answer-records are filed in numerical order according to
the number assigned
terminal-digit filing system - Answer-records are filed according to a 3-part number
made up of two-digit pairs; basic filing system contains 10,000 divisions made of 100
sections ranging 00 to 99 with 100 divisions within each section ranging from 00 to 99
Unit numbering system - Answer-health record identification system in which patient
receives a unique MRN at time of first encounter that is used for all subsequent
encounters
Basic interoperability - Answer-relates to the ability to successfully transmit and receive
data from one computer to another
Clinical Care Classification (CCC) - Answer-two interrelated taxonomies (CCC of
Nursing Diagnoses and outcomes, and CCC of Nursing Interventions and Actions) that
provide a standardized framework for documenting patient care in hospitals, home
health agencies, ambulatory care clinics, and other healthcare settings
clinical information model - Answer-outcome of the transitions of care (ToC) initiative
consisting of the unambiguous, clinically-relevant definitions of the core data elements
that should be included in care transitions
functional interoperability - Answer-refers to sending messages between computers with
a shared understanding of the structure and format of the message
interoperability - Answer-capability of different information systems and software
applications to communicate and exchange data
Lexicon - Answer-vocabulary used in a language or subject area by a particular speaker
or group of speakers; collection of words or terms and meanings for a particular domain
(drug terms in healthcare)
,mapping - Answer-process of associating concepts from one coding system with
concepts from another coding system and defining their equivalence in accordance with
a documented rationale and a given purpose
MEDCIN - Answer-a proprietary clinical terminology developed as a point-of-care tool
for electronic medical record documentation at the time and place of patient care
Medical Subject Headings database (MeSH) - Answer-National Library of Medicine's
controlled vocabulary thesaurus; consists of terms naming descriptors in a hierarchical
structure that permits searching at various levels of specificity
morphology - Answer-science of structure and form of organisms without regard to
function
multiaxial - Answer-the ability of a nomenclature to express the meaning of a concept
across several axes
reference terminology - Answer-a set of concepts and relationships that provide a
common consultation point for the comparison and aggregation of data about the entire
healthcare process, recorded by multiple individuals, systems, or institutions
RxNorm - Answer-clinical drug nomenclature developed by FDA, Department of
Veterans Affairs, and HL7 to provide standard names for clinical drugs and
administered dose forms
semantic interoperability - Answer-mutual understanding of the meaning of data
exchanged between information systems
Systemized Nomenclature of Medicine--Clinical Terminology/Reference Terminology
(SNOMED CT/RT) - Answer-most comprehensive, multilingual clinical healthcare
terminology in the world
CT--contributes to improvement of patient care by underpinning development of EHRs
that record clinical information in ways that enable meaning-based retrieval
RT--reference terminology by inclusion of elementary mapping to ICD-9-CM
topography - Answer-code that describes the site of origin of the neoplasm and uses the
same three- and four-character categories as in the neoplasm section of the second
chapter of ICD-10; description of a part of the body
Transitions of Care (ToC) initiative - Answer-one of the projects of the Standards and
Interoperability (S&I) Framework; exchange of clinical summaries is hampered by
ambiguous common definitions of what data elements must at a minimum be
exchanged, how they must be encoded, and how those common semantic elements
map to Meaningful Use specified formats
,Unified Medical Language System (UMLS) - Answer-program initiated by National
Library of Medicine to build an intelligent, automated system that can understand
biomedical concepts, words, and expressions and their interrelationships; includes
concepts and terms from many different source vocabularies
accession number/registry - Answer-number assigned to each case as it is entered in
cancer registry; list of cases in cancer registry in order by which they were entered
Agency for Healthcare Research and Quality (AHRQ) - Answer-branch of US Public
Health Service that supports general health research and distributes research findings
and treatment guidelines with the goal of improving the quality, appropriateness, and
effectiveness of healthcare services
aggregate data - Answer-data extracted from individual health records and combined to
form de-identified information about groups of patients that can be compared and
analyzed
cardinality - Answer-maximum number of occurrences of each entity that occurrences of
other entities can link to
data modeling - Answer-process of determining the users' information needs and
identifying relationships among the data
Accountable Care Organizations (ACOs) - Answer-group of service providers working
together to manage and coordinate care to Medicare fee-for-service beneficiaries
biotechnology - Answer-field devoted to applying techniques of biochemistry, cellular
biology, biophysics, and molecular biology to address issues related to humans,
agriculture, and the environment (EX: Pharma and medical device)
deemed status - Answer-designates facility is in compliance with Medicare Conditions of
Participation
Health Maintenance Organization (HMO) - Answer-usually only pays for care within own
network; primary doctor coordinates care
Health Savings Account (HSA) - Answer-savings accounts designed to help people
save for future medical and retiree health costs on a tax-free basis--part of 2003
Medicare bill--AKA medical savings accounts
Integrated Delivery System (IDS) - Answer-combines financial and clinical aspects of
healthcare and uses a group of healthcare providers, selected on basis of quality and
cost management criteria, to furnish comprehensive health services across the
continuum of care
, investor-owned hospital chain - Answer-group of for-profit healthcare facilities owned by
stockholders
Managed Care/Managed Care Organization (MCO) - Answer-delivers medical care and
manages all aspects of care or payment of care by limiting providers, discounting
payment, or limiting access to care. AKA coordinated care organization
medical staff bylaws - Answer-spell out qualifications for physicians before they are able
to practice in a given hospital. legally binding--changes to "laws" must be approved by a
vote of medical staff and hospital's governing body
medical staff classification - Answer-organization of physicians according to clinical
assignment
Multihospital system - Answer-two or more hospitals owned, leased, sponsored, or
contract managed by a central organization
network - Answer-group of hospitals, physicians, providers, or payers collaborating to
coordinate and deliver services to their community
Point of Service (POS) plan - Answer-managed care plan where enrollees are
encouraged to select healthcare providers from a network under contract, but are
allowed to go out of network and pay a larger share of the cost
Preferred Provider Organization (PPO) - Answer-network contractually agreed to
specified reimbursement, providing reimbursement for covered benefits regardless if in
network, and offered by non-HMOs
retail clinics - Answer-treat non-life-threatening acute illness and offer routine wellness
services--flu shots, physicals, prescription refills, etc
Surgeon General - Answer-appointed by POTUS. has responsibility for public health
service workforce
telehealth - Answer-system that links healthcare organizations and patients from
different geographic locations and transmits texts and images for medical consultation
and treatment
TRICARE - Answer-covers care for retired veterans, active military members, and
dependents of active and retired members of the 7 armed forces
Value-Based Purchasing (VBP) - Answer-pays for care that rewards better value,
patient outcomes, and innovation, rather than just volume of care provided
data - Answer-raw facts generally stored as characters, words, symbols,
measurements, or statistics
