Abbreviated Injury Scale (AIS)
A set of numbers used in a trauma registry to indicate the nature and severity of injuries by body system
Abbreviations
Shortened forms of words or phrases; in healthcare,when there is more than one meaning for an approved abbreviation, only one meaning should be used or the context in which the abbreviation is to be used should be identified
ABC Codes
A terminology created by Alternative Link that describes alternative medicine, nursing, and other integrative healthcare interventions
Aberrancy
Services in medicine that deviate from what is typical in comparison to the national norm
Ability (achievement) tests
Tests used to assess the skills an individual already possesses; Also called performance tests
Abnormal Involuntary Movement Scale (AIMS)
A standardized form that can be used in facilities to document involuntary movements
Abortion
The expulsion or extraction of all (complete) or any part (incomplete) of the placenta or membranes, without an identifiable fetus or with a live-born infant or a stillborn infant weighing less than 500 grams
Absolute frequency
The number of times that a score of value occurs in a data set
Abstract
Brief summary of the major parts of a research study
Abstracting
1. The process of extracting information from a document to create a brief summary of a patient's illness, treatment, and outcome 2. The process of extracting elements of data from a source document or database and entering them into an automated system
Abuse
Provider, supplier, and practitioner practices that are inconsistent with accepted sound fiscal, business, or medical practices that directly or indirectly may result in unnecessary costs to the program, improper payment, services that fail to meet professionally recognized standards of care or are medically unnecessary, or services that directly or indirectly result in adverse patient outcomes or delays in appropriate diagnosis or treatment
Abuses
Coding errors that occur without intent to defraud the government
Accept assignment
A term used to refer to a provider's or a supplier's acceptance of the allowed charges (from a fee schedule) as payment in full for services or materials provided
Acceptance testing
Final review during EHR implementation to ensure that all tests have been performed and all issues have been resolved; usually triggers the final payment for the system and when a maintenance contract becomes effective
Acceptance theory of authority
A management theory based on the principle that employees have the freedom to choose whether they will follow managerial directions
Access
1. The ability of a subject to view, change, or communicate with an object in a computer system 2. One of the rights protected by the Privacy Rule; an individual has a right of access to inspect and obtain a copy of his or her own PHI that is contained in a designated record set, such as a health record
Access control
1. A computer software program designed to prevent unauthorized use of an information resource 2. The process of designing, implementing, and monitoring a system for guaranteeing that only individuals who have a legitimate need are allowed to view or amend specific data sets
Access control grid
A tabular representation of the levels of authorization granted to users of a computer system's information and resources
Access control system
A system that defines who has access to what information in a computer system and specifies each user's rights and/or restrictions with respect to that information
Accession number
A number assigned to each case as it is entered in a cancer registry
Accession registry
A list of cases in a cancer registry in the order in which they were entered
Accidents/incidents
Those mishaps, misfortunes, mistakes, events, or occurrences that can happen during the normal daily routines and activities in the long-term care setting
Accommodating
In business, the practice whereby one party in a conflict or disagreement gives in to the other party as a temporary solution
Account
A subdivision of assets, liabilities, and equities in an organization's financial management system
Accountability
1. The state of being liable for a specific activity 2. All information is attributable to its source (person or device)
Accountable
Required to answer to a supervisor for performance results
Accountable Care Organization (ACO)
An organization of healthcare providers accountable for the quality, cost, and overall care of Medicare beneficiaries who are assigned and enrolled in the traditional fee-for-service program
Accounting
1. The process of collecting, recording, and reporting an organization's financial data 2. A list of all disclosures made of a patient's health information
Accounting entity
The business structure, including the activities and records to be maintained for the preparation of an individual organization's financial statements
Accounting of disclosures
HIPAA requirement to list, upon patient request, all disclosures that meet the criteria. Currently, this does not require accounting for disclosures for treatment, payment, and healthcare operations (TPO), but under ARRA this changes to include these disclosures; awaiting final regulations
Accounting period
The entire process of identifying and recording a transaction and ultimately reporting it as part of an organization's financial statement
Accounting rate of return
The projected annual cash inflows, minus any applicable depreciation, divided by the initial investment
Accounts Not Selected for Billing Report
A daily financial report used to track the many reasons why accounts may not be ready for billing
Accounts payable (A/P)
Records of the payments owed by an organization to other entities
Accounts receivable (A/R)
1. Records of the payments owed to the organization by outside entities such as third-party payers and patients 2. Department in a healthcare facility that manages the accounts owed to the facility by customers who have received services but whose payment is made at a later date
Accreditation
1. A voluntary process of institutional or organizational review in which a quasi-independent body created for this purpose periodically evaluates the quality of the entity's work against preestablished written criteria 2. A determination by an accrediting body that an eligible organization, network, program, group, or individual complies with applicable standards 3. The act of granting approval to a healthcare organization based on whether the organization has met a set of voluntary standards developed by an accreditation agency
Accreditation Association for Ambulatory Health Care (AAAHC)
A professional organization that offers accreditation programs for ambulatory and outpatient organizations such as single-specialty and multispecialty group practices, ambulatory surgery centers, college/university health services, and community health centers
Accreditation Commission for Health Care (ACHC)
An organization that provides quality standards and accreditation programs for home health and other healthcare organizations
Accreditation organization
A professional organization that establishes the standards against which healthcare organizations are measured and conducts periodic assessments of the performance of individual healthcare organizations
Accreditation standards
Preestablished statements of the criteria against which the performance of participating healthcare organizations will be assessed during a voluntary accreditation
Accredited Standards Committee X12 (ASC X12)
A committee of the American National Standards Institute (ANSI) responsible for the development and maintenance of electronic data interchange (EDI) standards for many industries. The ASC 'X12N' is the subcommittee of ASC X12 responsible for the EDI health insurance administrative transactions such as 837 Institutional Health Care Claim and 835 Professional Health Care Claim forms
Accrediting body
A professional organization that establishes the standards against which healthcare organizations are measured and conducts periodic assessment of the performance of individual healthcare organizations
Accrete
The term used by Medicare regarding the process of adding new members to a health plan
Accrual accounting
A method of accounting that requires business organizations to report income in the period earned and to deduct expenses in the period incurred
Accrue
The process of recording known transactions in the appropriate time period before cash payments/receipts are expected or due
Accuracy
The extent to which information reflects the true, correct, and exact description of the care that was delivered with respect to both content and timing
Acid-test ratio
A ratio in which the sum of cash plus short-term investments plus net current receivables is divided by total current liabilities
Acknowledgement
A form that provides a mechanism for the resident to recognize receipt of important information
ACOG
American College of Obstetrics and Gynecology
Acquired immunodeficiency syndrome (AIDS)
A retroviral disease caused by infection with human immunodeficiency virus (HIV)
Acquisition
One healthcare entity purchase of another healthcare entity in order to acquire control of all of its assets
Actinotherapy
The use of ultraviolet light therapy in the treatment of skin diseases
Action plan
A set of initiatives that are to be undertaken to achieve a performance improvement goal
Action steps
Specific plans an organization intends to accomplish in the near future as an effort toward achieving its long-term strategic plan
Active listening
The application of effective verbal communication skills as evidenced by the listener's restatement of what the speaker said
Active membership
Individuals interested in the AHIMA purpose and willing to abide by the Code of Ethics are eligible for active membership. Active members in good standing shall be entitled to all membership privileges including the right to vote
Active record
A health record of an individual who is a currently hospitalized inpatient or an outpatient
Activities of daily living (ADL)
The basic activities of self-care, including grooming, bathing, ambulating, toileting, and eating
Activity-based budget
A budget based on activities or projects rather than on functions or departments
Activity-based costing (ABC)
An economic model that traces the costs or resources necessary for a product or customer
Activity date or status
The element in the chargemaster that indicates the most recent activity of an item
Actor
The role a user plays in a system
Actual charge
1. A physician's actual fee for service at the time an insurance claim is submitted to an insurance company, a government payer, or a health maintenance organization; may differ from the allowable charge 2. Amount provider actually bills a patient, which may differ from the allowable charge
Acute care
Medical care of a limited duration that is provided in an inpatient hospital setting to diagnose and/or treat an injury or a short-term illness
Acute care prospective payment system
The Medicare reimbursement methodology system referred to as the inpatient prospective payment system (IPPS). Hospital providers subject to the IPPS utilize the Medicare Severity-Diagnosis Related Groups (MS-DRGs) classification system, which determines payment rates
ADFM
Active duty family member; a designation used under TRICARE
Ad hoc committee
A group of individuals who join together to solve a particular task or problem
Addendum
A late entry added to a health record to provide additional information in conjunction with a previous entry. The late entry should be timely and bear the current date and reason for the additional information being added to the health record
Addition of entries
Changes to the health record in the form of late entries, amendments, or addenda
Add-on codes
In CPT coding, add-on codes are referred to as additional or supplemental procedures. Add-on codes are indicated with a '+' symbol and are to be reported in addition to the primary procedure code. Add-on codes are not to be reported as stand-alone codes and are exempt from use of the -51 modifier
Addressable standards
The implementation specifications of the HIPAA Security Rule that are designated 'addressable' rather than 'required'; to be in compliance with the rule, the covered entity must implement the specification as written, implement an alternative, or document that the risk for which the addressable implementation specification was provided either does not exist in the organization, or exists with a negligible probability of occurrence
Adjunct diagnostic or therapeutic unit
An organized unit of an inpatient hospital (other than an operating room, delivery room, or medical care unit) with facilities and personnel to aid physicians in the diagnosis and treatment of illnesses or injuries through the performance of diagnostic or therapeutic procedures; Also called ancillary unit
Adjusted clinical groups (ACGs)
A classification system that groups individuals according to resource requirements and reflects the clinical severity differences among the specific groups; formerly called ambulatory care groups
Adjusted historic payment base (AHPB)
The weighted average prevailing charge for a physician service applied in a locality for 1991 and adjusted to reflect payments for services with charges below the prevailing charge levels and other payment limits; determined without regard to physician specialty and reviewed and updated yearly since 1992
Adjusted hospital autopsy rate
The proportion of hospital autopsies performed following the deaths of patients whose bodies are available for autopsy
Adjustment
The process of writing off an unpaid balance on a patient account to make the account balance
Administrative agencies
Executive branch agencies; source of administrative law
Administrative agency tribunals
A form of alternative dispute resolution in which tribunals are created by statute or the Constitution to hear disputes arising from administrative law
Administrative controls
Policies and procedures that address the management of computer resources
Administrative data
Coded information contained in secondary records, such as billing records, describing patient identification, diagnoses, procedures, and insurance
Administrative information
Information used for administrative and healthcare operations purposes, such as billing and quality oversight
Administrative information systems
A category of healthcare information systems that supports human resources management, financial management, executive decision support, and other business-related functions
Administrative law
A body of rules and regulations developed by various administrative entities empowered by Congress; falls under the umbrella of public law
Administrative law judge
A hearings officer who conducts appeal conflicts between providers of services, or beneficiaries, and Medicare contractors
Administrative management theory
A subdivision of classical management theory that emphasizes the total organization rather than the individual worker and delineates the major management functions
Administrative provisions
Documented, formal practices to manage data security measures throughout the healthcare organization
Administrative safeguards
Administrative actions such as policies and procedures and documentation retention to manage the selection, development, implementation, and maintenance of security measures to protect electronic protected health information and manage the conduct of the covered entity's or business associate's workforce in relation to the protection of that information
Administrative services
Business-related services provided by an insurance organization to self-insured employers or other parties according to an administrative services only contract (for example, actuarial support, benefit plan design, claims processing, data recovery and analysis, employee benefits communication, financial advice, medical care conversions, stop-loss coverage, and other services as requested)
Administrative services only (ASO) contract
An agreement between an employer and an insurance organization to administer the employer's self-insured health plan
Administrative simplification
A term referring to the Health Insurance Portability and Accountability Act (HIPAA) provisions which include standards for transactions and code sets that are used to exchange health data, standard identifiers for use on transactions, and privacy and security standards to protect personal health information. HIPAA included these administrative simplification provisions in order to improve the efficiency and effectiveness of the healthcare system.
Admissibility
The condition of being admitted into evidence in a court of law
Admission agreement
A legal contract signed by the resident that specifies the long-term care facility's responsibilities and fees for providing healthcare and other services
Admission date
The date the patient was admitted for inpatient care, outpatient service, or start of care. In the inpatient hospital setting, the admission date is the hospital's formal acceptance of a patient who is to receive healthcare services while receiving room, board, and continuous nursing services
Admissions and readmissions processing policy
A policy that provides the guidelines that are required when a resident is admitted or readmitted to the facility
Admission-discharge-transfer (ADT)
The name given to software systems used in healthcare facilities that register and track patients from admission through discharge including transfers; usually interfaced with other systems used throughout a facility such as an electronic health record or lab information system
Admission type
The required classification used to indicate the priority of an admission/visit required for submitting claims using the electronic 837I format or the equivalent CMS-1450 claim form
Admission utilization review
A review of planned services (intensity of service) and/or a patient's condition (severity of illness) to determine whether care must be delivered in an acute-care setting
Admitting diagnosis
A provisional description of the reason why a patient requires care in an inpatient hospital setting
Adoption
The decision to purchase, implement, and utilize an information system such as the EHR
Adult day care
Group or individual therapeutic services provided during the daytime hours to persons outside their homes; usually provided for individuals with geriatric or psychiatric illnesses
Adult health questionnaire
See patient history questionnaire
Adult learning
Self-directed inquiry aided by the resources of an instructor, colleagues/fellow students, and educational materials
Advance beneficiary notice (ABN)
A statement signed by the patient when he or she is notified by the provider, prior to a service or procedure being done, that Medicare may not reimburse the provider for the service, wherein the patient indicates that he will be responsible for any charges
Advanced decision support
Automated clinical practice guidelines that are built in to electronic health record systems and designed to support clinical decision making
Advance directive
A legal, written document that describes the patient's preferences regarding future healthcare or stipulates the person who is authorized to make medical decisions in the event the patient is incapable of communicating his or her preferences
Advanced practice registered nurse (APRN)
The term being increasingly used by legislative and governing bodies to describe the collection of registered nurses that practice in the extended role beyond the normal role of basic registered nursing
Adverse action
A term used to refer to an action taken against a practitioner's clinical privileges or medical staff membership in a healthcare organization; Also called licensure disciplinary action
Adverse drug event
A patient injury resulting from a medication, either because of a pharmacological reaction to a normal dose, or because of a preventable adverse reaction to a drug resulting from an error
Adverse drug reaction (ADR)
Unintended, undesirable, or unexpected effects of prescribed medications or of medication errors that require discontinuing a medication or modifying the dose, require initial or prolonged hospitalization, result in disability, require treatment with a prescription medication, result in cognitive deteriororation or impairment, are life threatening, result in death, or result in congenital anomalies
Adverse patient occurrences (APOs)
Occurrences such as admission for adverse results of outpatient management, readmission for complications, incomplete management of problems on previous hospitalization, or unplanned removal, injury, or repair of an organ or structure during surgery; covered entities must have a system for concurrent or retrospective identification through medical chart-based review according to objective screening criteria
Adverse selection
A situation in which individuals who are sicker than the general population are attracted to a health insurance plan, with adverse effects on the plan's costs
Affiliated covered entity
Legally separate covered entities, affiliated by common ownership or control; for purposes of the Privacy Rule, these legally separate entities may refer to themselves as a single covered entity
Affinity diagram
A graphic tool used to organize and prioritize ideas after a brainstorming session
Affinity grouping
A technique for organizing similar ideas together in natural groupings
Aftercare
Healthcare services that are provided to a patient after a period of hospitalization or rehabilitation and are administered with the objective of improving or restoring health to the degree that aftercare is no longer needed
Against medical advice (AMA)
The discharge status of patients who leave a hospital after signing a form that releases the hospital from any responsibility or who leave a hospital without notifying hospital personnel
Age Discrimination in Employment Act (1967)
Federal legislation that prohibits employment discrimination against persons between the ages of 40 and 70 and restricts mandatory retirement requirements except where age is a bona fide occupational qualification
Agency for Healthcare Research and Quality (AHRQ)
The branch of the 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
Agenda for Change
An initiative undertaken by the Joint Commission that focused on changing the emphasis of the accreditation process from structure to outcomes
Aggregate data
Data extracted from individual health records and combined to form de-identified information about groups of patients that can be compared and analyzed
Aggregate information system
The combining of various data sets in order to compile overview or summary statistics
Aging of accounts
The practice of counting the days, generally in 30-day increments, from the time a bill was sent to the payer to the current day
AHA Coding Clinic for HCPCS
The official coding advice resource for coding information on HCPCS CPT codes for hospital providers and certain HCPCS level II codes for hospitals, physicians, and other healthcare professionals
AHIMA Standards of Ethical Coding
The American Health Information Management Association's principles of professional conduct for coding professionals involved in diagnostic and/or procedural coding or other health record data abstraction
Alarm
A type of warning that is generated by an automated medical device
Alert
A software-generated warning that is based on a set of clinical rules built in to a healthcare information system
Algorithm
A procedure for solving a mathematical problem in a finite number of steps, which frequently involves repetition of an operation
Algorithmic translation
A process that involves the use of algorithms to translate or map clinical nomenclatures among each other or to map natural language to a clinical nomenclature or vice versa
Alias
A name added to, or substituted for, the proper name of a person; an assumed name
Alias policy
A policy that is implemented when resident confidentiality is required by the resident, family, or responsible party
Allied health professional
A credentialed healthcare worker who is not a physician, nurse, psychologist, or pharmacist (for example, a physical therapist, dietitian, social worker, or occupational therapist)
Allowable charge
Average or maximum amount a third-party payer will reimburse providers for a service
All patient diagnosis-related groups (AP-DRGs)
A case-mix system developed by 3M and used in a number of state reimbursement systems to classify non-Medicare discharges for reimbursement purposes
All patient refined diagnosis-related groups (APR-DRGs)
An expansion of the inpatient classification system that includes four distinct subclasses (minor, moderate, major, and extreme) based on the severity of the patient's illness
ALOS
See average length of stay
Alphabetic filing system
A system of health record identification and storage that uses the patient's last name as the first component of identification and his or her first name and middle name or initial for further definition
Alphanumeric filing system
A system of health record identification and storage that uses a combination of alphabetic letters (usually the first two letters of the patient's last name) and numbers to identify individual records
Alteration
Modifying the natural anatomic structure of a body part without affecting the function of the body part. The principal purpose of this procedure is to improve the patient's appearance
Alternative delivery system (ADS)
A type of healthcare delivery system in which health services are provided in settings such as skilled and intermediary facilities, hospice programs, nonacute outpatient programs, and home health programs, which are more cost-effective than in the inpatient setting
Alternative hypothesis
A hypothesis that states that there is an association between independent and dependent variables
Alternative Link
The original developer of the ABC codes
Ambulatory care
Preventive or corrective healthcare services provided on a nonresident basis in a provider's office, clinic setting, or hospital outpatient setting
Ambulatory care information system
A type of information system designed specifically for use and support in ambulatory care settings
Ambulatory care organization
A healthcare provider or facility that offers preventive, diagnostic, therapeutic, and rehabilitative services to individuals not classified as inpatients or residents
Ambulatory Care Quality Alliance
An organization consisting of a broad base of healthcare professionals who work collaboratively to improve healthcare quality and patient safety through performance measurement, data aggregation, and reporting in the ambulatory care setting
Ambulatory payment classification (APC)
Hospital outpatient prospective payment system (OPPS). The classification is a resource-based reimbursement system. The payment unit is the ambulatory payment classification group (APC group)
Ambulatory payment classification group (APC group)
Basic unit of the ambulatory payment classification (APC) system. Within a group, the diagnoses and procedures are similar in terms of resources used, complexity of illness, and conditions represented. A single payment is made for the outpatient services provided. APC groups are based on HCPCS/CPT codes. A single visit can result in multiple APC groups. APC groups consist of five types of service- significant procedures, surgical services, medical visits, ancillary services, and partial hospitalization. The APC group was formerly known as the ambulatory visit group (AVG) and ambulatory patient group (APG)
Ambulatory payment classification (APC) relative weight
A number reflecting the expected resource consumption of cases associated with each APC, relative to the average of all APCs, that is used in determining payment under the Medicare hospital outpatient prospective payment system (OPPS)
Ambulatory payment classification (APC) system
The Medicare reimbursement methodology system referred to as the hospital outpatient prospective payment system (OPPS). Hospital providers subject to the OPPS utilize the ambulatory payment classification (APC) system, which determines payment rates
Ambulatory surgery center (ASC) payment rate
The Medicare ASC reimbursement methodology system referred to as the ambulatory surgery center (ASC) payment system. The ASC payment system is based on the ambulatory payment classifications (APCs) utilized under the hospital OPPS
Ambulatory surgery center or ambulatory surgical center (ASC)
Under Medicare, an outpatient surgical facility that has its own national identifier; is a separate entity with respect to its licensure, accreditation, governance, professional supervision, administrative functions, clinical services, recordkeeping, and financial and accounting systems; has as its sole purpose the provision of services in connection with surgical procedures that do not require inpatient hospitalization; and meets the conditions and requirements set forth in the Medicare Conditions of Participation
Ambulatory surgical center (ASC) list
The Medicare ASC list which indicates procedures that are covered and paid if performed in the ASC setting
Ambulatory surgical center (ASC) services
ASC diagnostic and therapeutic procedures which can be safely performed outside a hospital setting
Amendment
Alteration of health information by modification, correction, addition, or deletion
Amendment request
The right of individuals to ask that a covered entity amend their health records, as provided in Section 164.526 of the Privacy Rule
American Academy of Professional Coders (AAPC)
The American Academy of Professional Coders provides certified credentials to medical coders in physician offices, hospital outpatient facilities, ambulatory surgical centers, and in payer organizations
American Accreditation Healthcare Commission/URAC
A healthcare quality improvement organization that offers managed care organizations, as well as other organizations, accreditation to validate quality healthcare, and provides education and measurement programs
American Association for Accreditation of Ambulatory Surgery Facilities (AAAASF)
An organization that provides an accreditation program to ensure the quality and safety of medical and surgical care provided in ambulatory surgery facilities
American Association of Health Plans (AAHP)
The trade organization for health maintenance organizations, preferred provider organizations, and other network-based health plans created by the merger of the Group Health Association of America and the American Managed Care and Review Association
American Association of Medical Record Librarians (AAMRL)
The name adopted by the Association of Record Librarians of North America in 1944; precursor of the American Health Information Management Association
American Association of Preferred Provider Organizations (AAPPO)
A national association composed of preferred provider organizations (PPOs) and affiliate organizations, which advocates for consumer awareness of their healthcare benefits and advocates for greater access, choice, and flexibility
American College of Healthcare Executives (ACHE)
The national professional organization of healthcare administrators that provides certification services for its members and promotes excellence in the field
American College of Obstetricians and Gynecologists (ACOG)
The professional association of medical doctors specializing in obstetrics and gynecology
American College of Radiology-National Electrical Manufacturers Association (ACR-NEMA)
The professional organizations (ACR) and trade associations (NEMA) that work collaboratively to develop digital imaging standards
American College of Surgeons (ACS)
The scientific and educational association of surgeons formed to improve the quality of surgical care by setting high standards for surgical education and practice
American College of Surgeons Commission on Cancer
The organization that approves cancer-related programs, including cancer registries and trauma centers
American Correctional Association (ACA)
An organization that provides education, training, correctional certification, and accreditation for correctional healthcare organizations
American Dental Association (ADA)
A professional dental association dedicated to the public's oral health, ethics, science, and professional advancement
American Health Information Community (AHIC)
A public-private federal advisory committee associated with the Office of the National Coordinator that makes recommendations to the secretary on how to accelerate adoption of interoperable electronic health information technology
American Health Information Management Association (AHIMA)
The professional membership organization for managers of health record services and healthcare information systems as well as coding services; provides accreditation, advocacy, certification, and educational services
American Hospital Association (AHA)
The national trade organization that provides education, conducts research, and represents the hospital industry's interests in national legislative matters; membership includes individual healthcare organizations as well as individual healthcare professionals working in specialized areas of hospitals, such as risk management; one of the four Cooperating Parties on policy development for the use of ICD-9-CM
American Medical Association (AMA)
The national professional membership organization for physicians that distributes scientific information to its members and the public, informs members of legislation related to health and medicine, and represents the medical profession's interests in national legislative matters; maintains and publishes the Current Procedural Terminology (CPT) coding system
American Medical Informatics Association (AMIA)
A professional association for individuals, institutions, and corporations that promotes the development and use of medical informatics for patient care, teaching, research, and healthcare administration
American Medical Record Association (AMRA)
The name adopted by the American Association of Medical Record Librarians in 1970; precursor of the American Health Information Management Association
American National Standards Institute (ANSI)
An organization that governs standards in many aspects of public and private business; developer of the Health Information Technology Standards Panel
American Nurses Association (ANA)
The national professional membership association of nurses that works for the improvement of health standards and the availability of healthcare services, fosters high professional standards for the nursing profession, and advances the economic and general welfare of nurses
American Occupational Therapy Association (AOTA)
The nationally recognized professional association of more than 40,000 occupational therapists, occupational therapy assistants, and students of occupational therapy
American Osteopathic Association (AOA)
The professional association of osteopathic physicians, surgeons, and graduates of approved colleges of osteopathic medicine that inspects and accredits osteopathic colleges and hospitals
American Physical Therapy Association (APTA)
The national professional organization whose goal is to foster advancements in physical therapy practice, research, and education
American Psychiatric Association (APA)
The international professional association of psychiatrists and related medical specialists that works to ensure humane care and effective treatment for all persons with mental disorders, including mental retardation and substance-related disorders
American Psychological Association (APA)
The professional organization that aims to advance psychology as a science and profession and promotes health, education, and human welfare
American Recovery and Reinvestment Act of 2009 (ARRA)
An economic stimulus package enacted by the 111th United States Congress in February 2009; signed into law by President Obama on February 17, 2009; an unprecedented effort to jumpstart the economy, create/save millions of jobs, and put a down payment on addressing long-neglected challenges; an extraordinary response to a crisis unlike any since the Great Depression; includes measures to modernize our nation's infrastructure, enhance energy independence, expand educational opportunities, preserve and improve affordable healthcare, provide tax relief, and protect those in greatest need; Also called Recovery Act; Stimulus
American Society for Healthcare Risk Management (ASHRM)
The professional society for healthcare risk management professionals that is affiliated with the American Hospital Association and provides educational tools and networking opportunities for its members
American Society for Quality (ASQ)
A quality improvement organization whose members' interests are related to statistical process control, quality cost measurement and control, total quality management, failure analysis, and zero defects
American Society for Testing and Materials (ASTM)
A national organization whose purpose is to establish standards on materials, products, systems, and services
American Society for Testing and Materials Committee E31 (ASTM E31)-Healthcare Informatics
A committee within the American Society for Testing and Materials that creates standards on the content, structure, and functionality of electronic health record systems, health information confidentiality policies and procedures, health data security, and the exchange of information across clinical systems, such as laboratory devices with information systems
American Society for Testing and Materials Standard E1384 (ASTM E1384)-Standard Guide for Description of Content and Structure of an Automated Primary Record of Care
A standard that identifies the basic information to be included in electronic health records and requires the information to be organized into categories
American Standard Code for Information Interchange (ASCII)
Electronic code that represents text, which makes it possible to transfer data from one computer to another
Americans with Disabilities Act (ADA) of 1990
Federal legislation which ensures equal opportunity for and elimination of discrimination against persons with disabilities
America's Health Insurance Plans (AHIP)
A national trade association representing companies providing health benefits to Americans; formerly known as the Health Insurance Association of America (HIAA)
Analog
Data or information that is not represented in an encoded, computer-readable format
Analysis
Review of health record for proper documentation and adherence to regulatory and accreditation standards
Analysis of discharged health records policy
A policy that outlines steps to be taken to process discharged resident records
Analysis phase
The first phase of the systems development life cycle during which the scope of the project is defined, project goals are identified, current systems are evaluated, and user needs are identified
Analysis session
The process of mining a data segment
Analyte
Any material or chemical substance subjected to analysis
Anatomical modifiers
Two-digit CPT codes that provide information about the exact body location of procedures, such as -LT, Left side, and -TA, Left great toe
Ancillary packaging
The inclusion of routinely performed support services in the reimbursement classification of a healthcare procedure or service
Ancillary services
1. Tests and procedures ordered by a physician to provide information for use in patient diagnosis or treatment 2. Professional healthcare services such as radiology, laboratory, or physical therapy
Ancillary service visit
The appearance of an outpatient in a unit of a hospital or outpatient facility to receive services, tests, or procedures; ordinarily not counted as an encounter for healthcare services
Ancillary systems
Electronic systems that generate clinical information (such as laboratory information systems, radiology information systems, pharmacy information systems, and so on)
Ancillary unit
See adjunct diagnostic or therapeutic unit
Androgynous leadership
Leadership in which cultural stereotyped masculine and feminine styles are integrated into a more effective hybrid style
Anesthesia death rate
The ratio of deaths caused by anesthetic agents to the number of anesthesias administered during a specified period of time
Anesthesia report
The report that notes any preoperative medication and response to it, the anesthesia administered with dose and method of administration, the duration of administration, the patient's vital signs while under anesthesia, and any additional products given the patient during a procedure
Anesthetic risk
The risk of harm resulting from the administration of anesthetic agents
Antegrade
Extending or moving forward
Antipsychotic Dyskinesia Identification System
One of several standardized forms for assessing and documenting abnormal movements (of face, eyes, mouth/tongue, or body) that may occur in the course of treatment with some psychotropic medications; See also discus monitoring form
Antipsychotic medications
Drugs that are used in the management of psychotic conditions, bipolar disorders, or major depression with psychotic features
Any and all records
A phrase frequently used by attorneys in the discovery phase of a legal proceeding. Subpoena-based requests containing this phrase may create a situation where the record custodian or provider's legal counsel can work to limit the records disclosed to those defined by a particular healthcare entity's legal health record. Typically, this is only during a subpoena phase, unless the information is legally privileged or similarly protected; the discovery phase of litigation probably can be used to request any and all relevant materials
APC grouper
Software programs that help coders determine the appropriate ambulatory payment classification for an outpatient encounter
Appeal
1. A request for reconsideration of a denial of coverage or rejection of claim decision 2. The next stage in the litigation process after a court has rendered a verdict; must be based on alleged errors or disputes of law rather than errors of fact
Appellate court
Courts that hear appeals on final judgments of the state trial courts or federal trial courts
Append
The operation that results in adding information to documentation already in existence
Application controls
Security strategies, such as password management, included in application software and computer programs
Application programming interface (API)
A set of definitions of the ways in which one piece of computer software communicates with another or a programmer makes requests of the operating system or another application; operates outside the realm of the direct user interface
Applications and data criticality analysis
A covered entity's formal assessment of the sensitivity, vulnerabilities, and security of its programs and the information it generates, receives, manipulates, stores, and/or transmits
Application service provider (ASP)
A third-party service company that delivers, manages, and remotely hosts standardized applications software via a network through an outsourcing contract based on fixed, monthly usage, or transaction-based pricing
Applied artificial intelligence
An area of computer science that deals with algorithms and computer systems that exhibit the characteristics commonly associated with human intelligence
Applied healthcare informatics
Automated information systems applied to healthcare delivery business and workflow processes, including the diagnosis, therapy, and systems of managing health data and information within the healthcare setting
Applied research
A type of research that focuses on the use of scientific theories to improve actual practice, as in medical research applied to the treatment of patients
Appreciative inquiry
An organizational development technique in which successful practices are identified and expanded throughout the organization
Aptitude tests
Tests that assess an individual's general ability to learn a new skill
AQA Alliance
A broad-based coalition of physicians, consumers, purchasers, health insurance plans, and others who are committed to effectively and efficiently improve performance measurement, data aggregation, and reporting in the ambulatory care setting
Arbitration
A proceeding in which disputes are submitted to a third party or a panel of experts outside the judicial trial system
Architecture
The configuration, structure, and relationships of hardware (the machinery of the computer including input/output devices, storage devices, and so on) in an information system
Archival database
A historical copy of a database that is saved at a particular point in time. It is used to recover and/or restore the information in the database
Archive file
A file in a collection of files reserved for later research or verification for the purposes of security, legal processes, and/or backup
Arden syntax
A standard language for encoding medical knowledge representation for use in clinical decision support systems
Area of excellence
A describable skill, competence, or capability that a department or company cultivates to a level of proficiency
Arithmetic mean length of stay (AMLOS)
The average length of stay for all patients
Artificial intelligence (AI)
High-level information technologies used in developing machines that imitate human qualities such as learning and reasoning
Artificial neural network (ANN)
A computational technique based on artificial intelligence and machine learning in which the structure and operation are inspired by the properties and operation of the human brain
ASC X12
Accredited Standards Committee, Electronic Data Interchange; See Accredited Standards Committee X12 (ASC X12)
Assembler
A computer program that translates assembly language instructions into machine language
Assembly language
A second-generation computer programming language that uses simple phrases rather than the complex series of switches used in machine language
Assessment
The systematic collection and review of information pertaining to an individual who wants to receive healthcare services or enter a healthcare setting
Assessment completion date
According to the Centers for Medicare and Medicaid Services' instructions, the date by which a Minimum Data Set for Long-Term Care must be completed; that is, within 14 days of admission to a long-term care facility
Assessment final completion date
The date (within 32 days of the assessment's final completion date) on which the Centers for Medicare and Medicaid requires Minimum Data Set for Long-Term Care assessments to be electronically submitted to the facility's state Minimum Data Set for Long-Term Care database
Assessment indicator code
A component of the code used for Medicare billing by long-term care facilities
Assessment locking
A term that refers to the Centers for Medicare and Medicaid Services' requirement that long-term care facilities must encode Minimum Data Set assessments in a computerized file and edit the data items for compliance with data specifications
Assessment reference date (ARD)
The date that sets the designated end point of resident observation for all staff participating in the assessment
Assets
The human, financial, and physical resources of an organization
Assignment
An agreement between a physician and CMS whereby a physician or supplier agrees to accept the Medicare-approved amount as payment in full for services or supplies provided under Part B. Medicare pays the physician or supplier 80 percent of the approved amount after the annual $100 deductible has been met; the beneficiary pays the remaining 20 percent
Assignment of benefits
The transfer of one's interest or policy benefits to another party; typically the payment of medical benefits directly to a provider of care
Assisted living
A type of freestanding long-term care facility where residents receive necessary medical services but retain a degree of independence
Association for Healthcare Documentation Integrity (AHDI)
Formerly the American Association for Medical Transcription (AAMT), the AHDI has a model curriculum for formal educational programs that includes the study of medical terminology, anatomy and physiology, medical science, operative procedures, instruments, supplies, laboratory values, reference use and research techniques, and English grammar
Association of American Medical Colleges (AAMC)
The organization established in 1876 to standardize the curriculum for medical schools in the United States and to promote the licensure of physicians
Association of Clinical Documentation Improvement Specialists (ACDIS)
Formed in 2007 as a community in which clinical documentation improvement professionals could communicate resources and strategies to implement successful programs and achieve professional growth
Association of Record Librarians of North America (ARLNA)
Organization formed 10 years after the beginning of the hospital standardization movement whose original objective was to elevate the standards of clinical recordkeeping in hospitals, dispensaries, and other healthcare facilities; precursor of the American Health Information Management Association
Association rule analysis (rule induction)
The process of extracting useful if/then rules from data based on statistical significance; See also rule induction
Assumption coding
The practice of assigning codes on the basis of clinical signs, symptoms, test findings, or treatments without supporting physician documentation
Assumptions
Undetermined aspects of a project that are considered to be true (for example, assuming that project team members have the right skill set to perform their duties)
ASTM International
Formerly known as the American Society for Testing and Materials, a system of standards developed primarily for various EHR management processes
ASTM Standard E1384-02a
Standard that identifies the content and structure for EHRs, covering all types of healthcare services, including acute-care hospitals, ambulatory care, skilled nursing facilities, home healthcare, and specialty environments
Asynchronous
Occurring at different times
Asynchronous transfer mode (ATM)
A topology for transmitting data across large wide-area networks
Atlas System
A severity-of-illness system commonly used in the United States and Canada
At risk contract
A type of managed care contract between Medicare and a payer or a payer and a provider according to which patients receive care during the entire term of the contract even if actual costs exceed the payment established by the agreement
Attending physician
The physician primarily responsible for the care and treatment of a patient
Attending physician identification
The unique national identification number assigned to the clinician of record at discharge who is responsible for the inpatient discharge summary
Attending Physician Statement (APS)
The standardized insurance claim form created in 1958 by the Health Insurance Association of America and the American Medical Association; See also COMB-1 form
Attestation
The act of applying an electronic signature to the content showing authorship and legal responsibility for a particular unit of information
Attorney-client privilege
An understanding that protects communication between client and attorney
Attorney in fact
Agent authorized by an individual to make certain decisions, such as healthcare determinations, according to a directive written by the individual
Attributable risk (AR)
A measure of the impact of a disease on a population (for example, measuring additional risk of illness as a result of exposure to a risk factor)
Attributes
1. Data elements within an entity that become the column or field names when the entity relationship diagram is implemented as a relational database 2. Properties or characteristics of concepts; used in SNOMED CT to characterize and define concepts
Attrition
See mortality
Audioconferencing
A learning technique in which participants in different locations can learn together via telephone lines while listening to a presenter and looking at handouts or books
Audit
1. A function that allows retrospective reconstruction of events, including who executed the events in question, why, and what changes were made as a result 2. To conduct an independent review of electronic system records and activities in order to test the adequacy and effectiveness of data security and data integrity procedures and to ensure compliance with established policies and procedures; See also external review
Auditability
The ability to do a methodical examination and verification of all information activities such as entering and accessing
Audit controls
The mechanisms that record and examine activity in information systems
Audit log
A chronological record of electronic system(s) activities that enables the reconstruction, review, and examination of the sequence of events surrounding or leading to each event and/or transaction from its beginning to end. Includes who performed what event and when it occurred
Audit reduction tool
Used to review the audit trail and compare it to facility-specific criteria and eliminate routine entries such as the periodic back-ups
Audit trail
1. A chronological set of computerized records that provides evidence of information system activity (log-ins and log-outs, file accesses) used to determine security violations 2. A record that shows who has accessed a computer system, when it was accessed, and what operations were performed; See also audit log
Auditing
The performance of internal and/or external reviews (audits) to identify variations from established baselines (for example, review of outpatient coding as compared with CMS outpatient coding guidelines)
Authenticate
Confirm by signing
Authenticated evidence
Evidence that appears to be relevant and has been shown to have a baseline authenticity or trustworthiness
Authentication
1. The process of identifying the source of health record entries by attaching a handwritten signature, the author's initials, or an electronic signature 2. Proof of authorship that ensures, as much as possible, that log-ins and messages from a user originate from an authorized source
Authenticity
The genuineness of a record, that it is what it purports to be; information is authentic if proven to be immune from tampering and corruption
Author
Person(s) who is (are) responsible and accountable for the health information creation, content, accuracy, and completeness for each documented event or health record entry
Authority
The right to make decisions and take actions necessary to carry out assigned tasks
Authorization
1. The granting of permission to disclose confidential information; as defined in terms of the HIPAA Privacy Rule, an individual's formal, written permission to use or disclose his or her personally identifiable health information for purposes other than treatment, payment, or healthcare operations 2. A patient's consent to the disclosure of protected health information (PHI); the form by which a patient gives consent to release of information
Authorization management
The process of protecting the security and privacy of the confidential data in a database
Authorization to disclose information
An authorization that allows the healthcare facility to verbally disclose or send health information to other organizations; See also authorization
Authorship
The origination or creation of recorded information attributed to a specific individual or entity acting at a particular time
Autoauthentication
1. A procedure that allows dictated reports to be considered automatically signed unless the health information management department is notified of needed revisions within a certain time limit 2. A process by which the failure of an author to review and affirmatively either approve or disapprove an entry within a specified time period results in authentication
Autocoding
The process of extracting and translating dictated and then transcribed free-text data (or dictated and then computer-generated discrete data) into ICD-9-CM and CPT evaluation and management codes for billing and coding purposes
Autodialing system
A method used to automatically call and remind patients of upcoming appointments
Automated clearinghouse (ACH)
An electronic network for the processing of financial transactions
Automated code assignment
Uses data that have been entered into a computer to automatically assign codes; uses natural language processing (NLP) technology-algorithmic (rules-based) or statistical-to read the data contained in a CPR
Automated codebook encoder
A type of encoder that mimics the codebook
Automated forms processing technology
Technology that allows users to electronically enter data into online digital forms and electronically extract data from online digital forms for data collection or manipulation; See also e-forms technology
Automatic log-off
A security procedure that ends a computer session after a predetermined period of inactivity
Autonomy
A core ethical principle centered on the individual's right to self-determination that includes respect for the individual; in clinical applications, the patient's right to determine what does or does not happen to him or her in terms of healthcare
Autopsy
The postmortem examinations of the organs and tissues of a body to determine the cause of death or pathological conditions
Autopsy rate
The proportion or percentage of deaths in a healthcare organization that are followed by the performance of autopsy
Autopsy report
Written documentation of the findings from a postmortem pathological examination
Availability
The accessibility for continuous use of data
Available for hospital autopsy
A situation in which the required conditions have been met to allow an autopsy to be performed on a hospital patient who has died
Average
The value obtained by dividing the sum of a set of numbers by the number of values
Average daily census
The mean number of hospital inpatients present in the hospital each day for a given period of time
Average duration of hospitalization
See average length of stay
Average length of stay (ALOS)
The mean length of stay for hospital inpatients discharged during a given period of time
Average payment rate (APR)
The amount of money the Centers for Medicare and Medicaid could pay a health maintenance organization for services rendered to Medicare recipients under a risk contract
Average record delinquency rate
The monthly average number of discharges divided by the monthly average number of delinquent records
Average wholesale price (AWP)
The price commonly used when negotiating pharmacy contracts
Avoiding
In business, a situation where two parties in conflict ignore that conflict
Awareness training
Training designed to help individuals understand and respond to information technology concerns