Data this..
Data that..
Data that..
A provider's written note is this type of data.
What is Unstructured Data?
This documentation must be completed 30 days before or 24 hours after admission and must be placed in the record within 24 hours after admission
What is history and physical (H&P)?
individually identifiable health information held or transmitted by a covered entity or business associate
What is protected health information (PHI)?
The right of an individual to be let alone
What is Privacy?
CCD
What is continuity of care document?
Data on groups of individuals that do not identify specific individuals
What is Aggregate Data?
discharge summaries must be completed within _____ days after discharge
What is 30 days?
process of reducing or eliminating a risk by implementing a control
What is mitigation?
intentionally altering a patient’s health record after a legal hold was placed on the record
What is Spoliation?
HL7 FHIR
What is Health Level 7 Fast Healthcare Interoperability Resources?
"data about data"
What is metadata?
These reviews help to catch incomplete documentation or unsigned orders while the patient is still in-house
What is concurrent review?
This safeguard automatically terminates an inactive session after 5 minutes of inactivity.
What is a technical safeguard?
This act was originally established to address fraud and abuse, health insurance continuity, and standards for electronic claims
What is Health Insurance Portability and Accountability Act (HIPAA) of 1996?
What is Uniform Hospital Discharge Dataset?
This database contains important patient health information enabling facilities to retrieve patient health data quickly
What is Master Patient Index?
DAILY DOUBLE:
NCVHS has identified three levels of interoperability. Name at least one.
Daily Double: Double points if all three are named.
What is basic, functional, and semantic?
This rule requires organizations to implement policies and procedures to safeguard the facility and equipment from unauthorized access, tampering, and theft.
What is the Security Rule?
This type of subpoena compels a person or organization to produce documents, records, or other tangible evidence relevant to a case
What is Subpoena Duces Tecum?
SNOMED-CT
What is Systematized Nomenclature of Medicine – Clinical Terms
This data quality principle ensures that data is available to authorized users when needed, with proper safeguards for security and privacy
What is accessibility?
ICD-10-PCS is based on a _____-character alphanumeric code.
What is seven?
the purpose of this document is to inform patients of how a healthcare provider may use and share the patient’s health information
What is a notice of privacy practices (npp)?
federal regulation that protects the confidentiality of patient records for individuals receiving substance use disorder (SUD) treatment
What is 42 CFR Part 2?
BAA
What is a Business Associate Agreement?