| Preface |
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xiii | |
| About the Authors |
|
xvii | |
| Acknowledgments |
|
xix | |
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Section 1 Data Content, Structure, And Information Governance |
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1 | (49) |
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Case 1-1 Subjective, Objective, Assessment and Plan (SOAP) Statements and the Problem-Oriented Health Record (POHR) |
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2 | (1) |
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Case 1-2 Problem-Oriented Record Format |
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3 | (2) |
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Case 1-3 Master Patient Index and Duplicate Health Record Number Assignment |
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5 | (2) |
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Case 1-4 Enterprise MPI (E-MPI) |
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7 | (1) |
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Case 1-5 Chart Checkout Template Screen Design and Data Quality |
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8 | (2) |
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Case 1-6 Patient Demographic Data Entry Template Screen Design and Data Quality |
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10 | (2) |
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Case 1-7 Encounter Abstract Template Screen Design and Data Quality |
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12 | (2) |
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Case 1-8 Coding Abstract Template Screen Design and Data Quality |
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14 | (2) |
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Case 1-9 Design a Template Screen for Radiology and Imaging Service Examinations |
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16 | (1) |
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Case 1-10 Documentation Requirements for the History and Physical Report |
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17 | (1) |
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Case 1-11 Focused Review of Patient Record Documentation: Operative Report |
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18 | (1) |
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Case 1-12 Data Collection in Long-Term Care: Minimum Data Set Version 3.0 |
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19 | (1) |
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Case 1-13 Data Collection for Joint Commission ORYX Performance Measures |
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20 | (1) |
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Case 1-14 Birth Certificate Reporting Project |
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21 | (12) |
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Case 1-15 Clinical Coding Systems and Technology |
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33 | (1) |
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Case 1-16 Text Messaging of ePHI |
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34 | (2) |
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Case 1-17 Joint Commission Mock Survey |
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36 | (1) |
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Case 1-18 Authentication of Patient Record Documentation |
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37 | (1) |
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Case 1-19 Copy and Paste in the EHR |
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38 | (1) |
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Case 1-20 Case Finding for Tumor Registry |
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39 | (1) |
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Case 1-21 Face Validity of Q1 Study on Births |
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40 | (2) |
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Case 1-22 Reproductive History Interpretation |
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42 | (1) |
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Case 1-23 Extract of Pertinent Inpatient Medical Documentation |
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43 | (1) |
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Case 1-24 Choosing a Personal Health Record |
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44 | (1) |
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Case 1-25 Personal Health Record Education |
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45 | (1) |
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Case 1-26 Clinical Vocabularies |
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46 | (1) |
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Case 1-27 Clinical Documentation Improvement Meeting |
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47 | (1) |
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Case 1-28 Breaking Down Classification Systems and Clinical Terminologies |
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48 | (1) |
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Case 1-29 Documentation Standards for the Hospital-Based Health Record |
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49 | (1) |
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Section 2 Information Protection: Access, Archival, Privacy, And Security |
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50 | (70) |
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Case 2-1 Monitoring Regulations Affecting Healthcare {Federal Register) |
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51 | (1) |
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Case 2-2 Alteration of Patient Record |
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52 | (1) |
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Case 2-3 Reporting Notifiable Diseases |
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53 | (2) |
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Case 2-4 Disclosure of Health Information Staff Privacy Training Test |
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55 | (2) |
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Case 2-5 Responsibilities of Disclosure of Health Information Coordinator |
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57 | (1) |
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Case 2-6 Disclosure of Health Information and the "Legal Health Record" |
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58 | (1) |
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Case 2-7 Authorization for Disclosure of Health Information |
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59 | (6) |
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Case 2-8 Processing a Request for Disclosure of Health Information |
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65 | (3) |
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68 | (1) |
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Case 2-10 Designated Record Set Identification |
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69 | (1) |
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Case 2-11 Processing Disclosure of Health Information |
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70 | (1) |
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Case 2-12 Valid Authorization for Disclosure of Health Information |
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71 | (1) |
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Case 2-13 Health Information Management Department Process for Subpoenas for Disclosure of Health Information |
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72 | (1) |
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Case 2-14 Validate Subpoenas for Disclosure of Health Information |
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73 | (4) |
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Case 2-15 Notice of Privacy Practices |
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77 | (2) |
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Case 2-16 Accounting for Disclosure of Protected Health Information under the Health Insurance Portability and Accountability Act |
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79 | (2) |
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Case 2-17 Legal Issues in Accounting for Disclosure of Protected Health Information to the Health Department |
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81 | (1) |
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Case 2-18 Patient Right to Amend Record |
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82 | (1) |
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Case 2-19 Institutional Process for Patient Request to Amend Record |
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83 | (1) |
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Case 2-20 Investigating Potential Privacy Violations |
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84 | (1) |
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Case 2-21 Investigation of Breach of Privacy |
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85 | (1) |
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Case 2-22 Privacy Violation by Former Employee |
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86 | (1) |
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Case 2-23 Privacy Plan Gap Analysis |
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87 | (1) |
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Case 2-24 Security Measures for Access to Protected Health Information |
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88 | (1) |
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Case 2-25 Access Controls |
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89 | (1) |
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Case 2-26 Mobile Security |
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90 | (1) |
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Case 2-27 Breach Notification |
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91 | (1) |
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Case 2-28 Breach of Information at Business Associate |
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92 | (1) |
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Case 2-29 Access to Health Information for Treatment |
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93 | (1) |
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Case 2-30 Updating the Retention and Destruction Policy for Healthcare Records |
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94 | (1) |
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Case 2-31 Retention Planning |
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95 | (1) |
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Case 2-32 Evaluating Records for Destruction |
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96 | (1) |
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Case 2-33 Developing a Documentation Destruction Plan |
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97 | (1) |
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Case 2-34 Business Associate Noncompliance |
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98 | (1) |
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Case 2-35 Employee System Access Termination Procedure |
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99 | (1) |
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Case 2-36 Contingency Planning |
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100 | (1) |
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Case 2-37 Business Continuity Planning |
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101 | (1) |
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Case 2-38 Evaluating Systems for Health Security Regulations Compliance |
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102 | (1) |
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103 | (1) |
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Case 2-40 Audit Trail Analysis |
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104 | (4) |
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Case 2-41 Password Management |
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108 | (1) |
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Case 2-42 Electronic Health Record Security Plan |
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109 | (1) |
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Case 2-43 Patient Identity Verification |
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110 | (1) |
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Case 2-44 Medical Identity Theft |
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111 | (1) |
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Case 2-45 Importance of Audit Trail |
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112 | (1) |
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Case 2-46 Monitoring Status of Federal Privacy and/or Security Laws and Regulations |
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113 | (1) |
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Case 2-47 Create Job Description for Chief Privacy Officer (Chief Security Officer) |
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114 | (1) |
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115 | (1) |
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Case 2-49 Risk Assessment |
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116 | (1) |
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Case 2-50 Privacy and the Use of Texting and E-mail |
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117 | (1) |
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Case 2-51 Conduct HIPAA Privacy Awareness Training |
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118 | (1) |
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Case 2-52 HIPAA Training Newsletter |
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119 | (1) |
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Section 3 Informatics, Analytics, And Data Use |
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120 | (49) |
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Case 3-1 System Conversion |
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121 | (2) |
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Case 3-2 System Interface |
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123 | (1) |
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Case 3-3 Data Relationships |
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124 | (1) |
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125 | (1) |
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Case 3-5 Database Development |
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126 | (1) |
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Case 3-6 Human Resource Database |
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127 | (1) |
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Case 3-7 Database Queries |
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128 | (1) |
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Case 3-8 Master Patient Index System Selection |
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129 | (1) |
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Case 3-9 System Life Cycle |
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130 | (1) |
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Case 3-10 Data Collection Questionnaire and Interview Questions for Systems Analysis |
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131 | (1) |
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Case 3-11 Developing a Data Collection Plan for Systems Analysis |
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132 | (1) |
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Case 3-12 Information System Project Steering Committee |
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133 | (1) |
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Case 3-13 Developing a System Selection Plan |
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134 | (1) |
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Case 3-14 Decision on System Replacement |
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135 | (6) |
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Case 3-15 Information System Testing Plan |
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141 | (1) |
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Case 3-16 Workflow Technology |
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142 | (1) |
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Case 3-17 Computerized Provider Order Entry Implementation |
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143 | (1) |
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Case 3-18 Normalization of Data Fields |
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144 | (1) |
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Case 3-19 Admission Report Design |
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145 | (1) |
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Case 3-20 Choosing Software Packages |
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146 | (1) |
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Case 3-21 Selecting an Internet-Based Personal Health Record |
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147 | (1) |
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Case 3-22 Data Warehouse Development |
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148 | (1) |
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Case 3-23 Human---Computer Interactions |
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149 | (1) |
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Case 3-24 Failure of an Electronic Health Record System |
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150 | (1) |
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Case 3-25 Intranet Functionality |
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151 | (1) |
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Case 3-26 Cloud Computing |
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152 | (1) |
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Case 3-27 Voice Recognition Editing |
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153 | (1) |
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Case 3-28 Single Vendor or Best of Breed |
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154 | (1) |
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Case 3-29 Functional Requirements of a Transcription System |
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155 | (1) |
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Case 3-30 Electronic Signatures |
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156 | (1) |
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Case 3-31 Health Information Exchange |
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157 | (1) |
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158 | (1) |
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Case 3-33 HL7 EHR System Functional Model |
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159 | (1) |
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160 | (1) |
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Case 3-35 Electronic Health Record Certification |
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161 | (1) |
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Case 3-36 Encoder Functional Requirements |
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162 | (1) |
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Case 3-37 Encoder Selection |
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163 | (1) |
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Case 3-38 Request for Information for Encoder Systems |
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164 | (1) |
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Case 3-39 Exchange of Health Information Standards |
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165 | (1) |
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Case 3-40 Version Control |
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166 | (1) |
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Case 3-41 Data Flow Diagrams |
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167 | (1) |
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Case 3-42 Assessment of EHR |
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168 | (1) |
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Section 4 Revenue Management |
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169 | (39) |
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Case 4-1 Qualification for Insurance |
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170 | (1) |
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Case 4-2 Medicare Coverage |
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171 | (1) |
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172 | (1) |
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Case 4-4 Calculating Commercial Insurance Reimbursement |
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173 | (1) |
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Case 4-5 Explanation of Benefits |
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174 | (1) |
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Case 4-6 Official Coding Resource |
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175 | (2) |
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Case 4-7 Capitation Profit |
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177 | (1) |
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Case 4-8 Selecting Coding Classification Systems |
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178 | (1) |
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Case 4-9 Estimated Medicare-Severity Diagnosis-Related Group Payments |
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179 | (2) |
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Case 4-10 Case Mix Index Trends |
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181 | (1) |
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Case 4-11 Top 10 Medicare-Severity Diagnosis-Related Groups |
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182 | (1) |
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Case 4-12 Case Mix Index Investigation |
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183 | (2) |
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Case 4-13 Case Mix Index Analysis |
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185 | (1) |
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Case 4-14 Medicare Provider Analysis and Review Data Analysis |
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186 | (2) |
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Case 4-15 Ambulatory Payment Classification |
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188 | (1) |
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Case 4-16 Discharged Not Final Billed Reduction |
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189 | (2) |
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Case 4-17 Chargemaster Audit |
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191 | (1) |
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Case 4-18 Chargemaster Maintenance |
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192 | (1) |
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Case 4-19 Monitoring Revenue Cycle |
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193 | (1) |
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Case 4-20 Utilization Review |
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194 | (1) |
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Case 4-21 Hierarchical Condition Categories |
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195 | (1) |
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Case 4-22 Inpatient Rehabilitation Facility Prospective Payment System |
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196 | (1) |
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Case 4-23 Medicare Physician Fee Schedule |
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197 | (1) |
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Case 4-24 Present on Admission |
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198 | (1) |
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Case 4-25 Calculating Cost to Charge Ratio |
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199 | (1) |
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Case 4-26 Calculating Reimbursement Rate |
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200 | (4) |
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Case 4-27 Calculating Denial Rate |
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204 | (4) |
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208 | (36) |
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Case 5-1 Hospital-Acquired Conditions |
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209 | (1) |
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Case 5-2 Coding Quality in ICD-10-CM |
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210 | (2) |
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Case 5-3 Developing a Coding Quality Plan |
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212 | (1) |
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Case 5-4 High-Risk Medicare-Severity Diagnosis-Related Groups |
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213 | (1) |
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Case 5-5 Medicare-Severity Diagnosis-Related Group Changes |
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214 | (1) |
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Case 5-6 Documentation Support for Principal Diagnosis |
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215 | (1) |
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Case 5-7 Improving Coding Quality |
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216 | (1) |
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Case 5-8 Physician Query Policy |
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217 | (2) |
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Case 5-9 Physician Query Evaluation |
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219 | (5) |
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Case 5-10 Physician Orders for Outpatient Testing |
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224 | (1) |
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Case 5-11 Monitoring Compliance Activities |
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225 | (1) |
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Case 5-12 Potential Compliance Issue |
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226 | (2) |
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Case 5-13 Documentation Improvement |
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228 | (1) |
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Case 5-14 Office of Inspector General Findings |
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229 | (1) |
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Case 5-15 National Coverage Determination |
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230 | (1) |
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Case 5-16 Local Care Determinations and Articles |
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231 | (1) |
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Case 5-17 Medical Necessity |
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232 | (1) |
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Case 5-18 Corrective Action Plan |
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233 | (1) |
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Case 5-19 Comprehensive Error Rate Testing Benchmarking |
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234 | (1) |
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Case 5-20 Recovery Audit Contractor Additional Documentation Limits |
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235 | (1) |
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Case 5-21 Clinical Documentation Improvement (CDI) Plan Evaluation |
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236 | (1) |
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Case 5-22 Medical Necessity Appeal Letter Education |
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237 | (1) |
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Case 5-23 Writing an Appeal Letter for an MS-DRG Change Denial |
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238 | (1) |
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Case 5-24 Documentation Improvement Presentation |
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239 | (1) |
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Case 5-25 Advanced Beneficiary Notices Audit |
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240 | (1) |
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Case 5-26 Clinical Documentation Metrics |
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241 | (2) |
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243 | (1) |
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244 | (87) |
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Case 6-1 Developing an Organizational Chart for Health Information Management |
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245 | (1) |
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Case 6-2 Writing a Policy and Procedure |
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246 | (2) |
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Case 6-3 Work Measurement Study |
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248 | (1) |
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Case 6-4 Evaluating Employees' Skills |
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249 | (1) |
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Case 6-5 Recruiting Resources |
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250 | (1) |
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Case 6-6 Recruitment Advertisement |
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251 | (1) |
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Case 6-7 Interviewing Job Applicants |
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252 | (2) |
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Case 6-8 Job Applicant and the Americans with Disabilities Act |
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254 | (1) |
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Case 6-9 Developing a Training Plan |
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255 | (1) |
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Case 6-10 Department Coverage |
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256 | (1) |
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Case 6-11 Decision Making |
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257 | (1) |
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Case 6-12 Progressive Disciplinary Approach |
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258 | (3) |
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Case 6-13 Falsification of Information on Employment Application |
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261 | (1) |
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Case 6-14 Time Management |
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262 | (2) |
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Case 6-15 Interdepartmental Communications |
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264 | (2) |
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266 | (1) |
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Case 6-17 Incentive-Based Compensation Programs |
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267 | (4) |
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Case 6-18 Payroll Budget Decisions |
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271 | (3) |
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Case 6-19 Budgeting for Reducing Payroll |
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274 | (2) |
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Case 6-20 Calculating Salary Increases |
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276 | (4) |
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Case 6-21 Calculating Department Operations Budget |
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280 | (2) |
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Case 6-22 Net Present Value (NPV) Method of Evaluating a Capital Expense |
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282 | (1) |
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Case 6-23 Accounting Rate of Return Method of Evaluating a Capital Expense |
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283 | (1) |
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Case 6-24 Payback Method of Evaluating a Capital Expense |
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284 | (2) |
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Case 6-25 Developing the Health Information Management Operations Budget |
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286 | (2) |
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Case 6-26 Developing the Health Information Management Department Budget |
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288 | (5) |
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Case 6-27 Updating Department Organizational Chart |
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293 | (1) |
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Case 6-28 Job Description Analysis |
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294 | (1) |
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Case 6-29 Productivity Study |
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295 | (1) |
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Case 6-30 Performance and Quality Improvement in a Coding Department |
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296 | (2) |
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Case 6-31 Instituting Productivity and Quality Standards for Imaging or Scanning Records |
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298 | (1) |
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Case 6-32 Evaluation of Transcription Department |
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299 | (2) |
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Case 6-33 Performance and Quality Evaluation and Improvement of the Health Information Management Department |
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301 | (3) |
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Case 6-34 Revision of the Information Management Plan |
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304 | (1) |
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Case 6-35 Defining a Project |
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305 | (1) |
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Case 6-36 Job Description for Project Manager |
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306 | (1) |
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Case 6-37 Forming Committees |
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307 | (2) |
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Case 6-38 Committee to Perform System Benefits Analysis |
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309 | (1) |
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Case 6-39 Project Management and Program Evaluation Review Technique Chart |
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310 | (2) |
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Case 6-40 Project Management and Analysis of a Gantt Chart |
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312 | (8) |
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Case 6-41 Creating a Gantt Chart |
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320 | (1) |
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Case 6-42 Evaluation of Project Management Budget Variance |
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321 | (2) |
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Case 6-43 Planning the Health Information Management Department for a New Facility |
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323 | (2) |
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Case 6-44 Planning Release of Information Department Functions for a New Facility |
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325 | (1) |
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Case 6-45 American Health Information Management Association Code of Ethics |
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326 | (1) |
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Case 6-46 Campaign Posters in the Clinic |
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327 | (1) |
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Case 6-47 Research Studies and Ethics |
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328 | (1) |
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Case 6-48 Health Information Management Staff and Confidentiality |
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329 | (1) |
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Case 6-49 Management Training Program |
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330 | (1) |
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Section 7 Healthcare Statistics And Research Methods |
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331 | |
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Case 7-1 Inpatient Service Days |
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332 | (2) |
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Case 7-2 Average Daily Census |
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334 | (1) |
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Case 7-3 Length of Stay (LOS) |
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335 | (2) |
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Case 7-4 Average Length of Stay |
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337 | (2) |
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Case 7-5 Percentage of Occupancy for Month |
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339 | (2) |
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Case 7-6 Percentage of Occupancy for Year with Change in Bed Count |
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341 | (1) |
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Case 7-7 Percentage of Occupancy by Unit |
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342 | (1) |
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Case 7-8 Consultation Rate |
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343 | (1) |
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344 | (1) |
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Case 7-10 Prevalence and Incident Rates |
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345 | (1) |
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Case 7-11 Comparative Health Data: Hospital Mortality Statistics |
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346 | (1) |
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Case 7-12 Joint Commission Hospital Quality Check |
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347 | (1) |
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Case 7-13 Hospital Comparative Data for Clinical Services |
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348 | (1) |
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Case 7-14 Nursing Home Comparative Data |
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349 | (1) |
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Case 7-15 Residential Care Facilities in Long-Term Care |
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350 | (1) |
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Case 7-16 Relative Risk Comparison |
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351 | (1) |
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Case 7-17 Determining Appropriate Formulas: Ratios |
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352 | (1) |
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Case 7-18 Calculating Obstetrics Statistics |
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353 | (2) |
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Case 7-19 Research Drug Overdose Mortality Trend |
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355 | (1) |
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Case 7-20 Hospital Statistics Spreadsheet |
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356 | (2) |
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Case 7-21 Benchmarks for Leading Causes of Death |
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358 | (1) |
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Case 7-22 U.S. Health Risks of Substance Use through Public Data |
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359 | (1) |
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Case 7-23 AHRQ Public Data Use of Most Common Diagnoses and Principal Procedures for U.S. Hospitalizations |
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360 | (1) |
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Case 7-24 Medicare-Severity Diagnosis-Related Groups and Revenue |
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361 | (1) |
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Case 7-25 Health Information Management State Association Board Review for Improvement Opportunities |
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362 | (1) |
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Case 7-26 Calculating Physician Service Statistics |
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363 | (1) |
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Case 7-27 Determining the Percentage of Patients with Unacceptable Waiting Time |
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364 | (1) |
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Case 7-28 Systems Analysis of Health Information Management Function from Clinical Experience |
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365 | (1) |
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Case 7-29 Clinical Quality Improvement Research |
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366 | (1) |
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Case 7-30 State Surveillance of Coronavirus Disease 2019 |
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367 | (1) |
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Case 7-31 Statistics on Septicemic Hospitalizations as Principal Diagnosis |
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368 | (1) |
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Case 7-32 Pain Assessment Study |
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369 | (1) |
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Case 7-33 Coronary Artery Bypass Graft Postoperative Length of Stay |
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370 | (2) |
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Case 7-34 Skyview Hospital Monthly Statistical Reporting |
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372 | (1) |
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Case 7-35 Dashboard of Coding Services |
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373 | |
