Exam (elaborations)
Intro to Health Information Management Technology_ Chapter 6
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Intro to Health Information Management Technology_ Chapter 6
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A list of the operations and surgical procedures performed in a healthcare facility, which is
sequenced according to the code numbers of the classification system in use.
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Operation or procedure index
,(1) the extent to which healthcare data are complete, accurate, consistent, and timely (2) a
security principle that keeps information from being modified or otherwise corrupted either
maliciously or accidentally.
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data integrity
Any manual or electronic notation (or recording) made by a physician or other healthcare
clinician related to a patient's medical condition or treatment.
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Clinical documentation
A descriptive list of the names, definitions, and attributes of data elements to be collected in
an information system or database whose purpose is to standardize definitions and ensure
consistent use.
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Data dictionary
Home healthcare setting
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Outcomes and Assessment Information Set (OASIS)
Program created to support reimbursement; however, with the implementation of EHRs and
the expanded uses of clinically coded data, these programs have shifted to facilitate an
accurate representation of healthcare services through complete and accurate patient
documentation within the record.
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Clinical Documentation Improvement (CDI)
Accuracy, accessibility, comprehensiveness, consistency, currency, definition, granularity,
precision, relevancy, and timeliness
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Ten data quality characteristics defined by AHIMA
Operating documents that describe the rules and regulations under which a healthcare
organization operates.
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