Across
- 3. The degree to which stated outcomes are attained.
- 6. An artificial intelligence technology that converts human language (structured or unstructured) into data that can be translated then manipulated by information systems.
- 11. Also called chart tracking system, is designed to identify the current location of the paper health record.
- 13. A system that tracks and records documentation omission due to deficiency in the health record that comes to the HIM department.
- 20. The scientific discipline that is concerned with the cognitive, information-processing, and communications tasks of healthcare practice, education, and research, including the information science and technology to support these tasks.
- 22. How the desired outcome is achieved or produced, particularly without wasting resources, such as time, personnel, and money.
- 23. Specialty software used by coders to select the appropriate code for the diagnosis(es) and procedure(s) supported by the health record.
- 24. A software program used to analyze the clinical data found in an electronic health record.
Down
- 1. Works with clinical providers, such as physicians and nurses, to lead them in the use of technology to improve quality of care, medical education, and healthcare research.
- 2. The science of examining raw data with the purpose of drawing conclusions about that information; a subset of informatics.
- 4. A system that tracks the disclosures made throughout the healthcare facility for reporting purposes.
- 5. Tracks information about the patient’s cancer from the time of diagnosis to the patient’s death. These systems are extremely complex and track very detailed information regarding diagnosis and treatment.
- 7. The recognized process assists in identifying ways to improve clinical documentation in the health record.
- 8. A valuable tool designed to manage the processing of requests for protected health information (PHI) received and processed by the HIM department.
- 9. An abstracting system that records information about the patient, the care provided to the patient, and the healthcare practitioner(s) involved in the care delivered.
- 10. Used by physicians to verbally record various medical reports such as history and physical examinations, discharge summaries, radiology reports, autopsy reports, catheterization reports, and other designated reports into the system.
- 12. Tracks patients with traumatic injuries from initial trauma treatment to death.
- 14. A tool that allows transcriptionists to type an acronym such as “CHF” and the full phrase “congestive heart failure” will automatically be spelled out, thus saving keystrokes and time.
- 15. A population-based dataset reporting to state and national agencies to track the epidemiology of the diseases and the treatment and outcomes of health and medical care of patients.
- 16. Lists diagnoses and procedures in alphabetic order much like the alphabetic index located in the International Classification of Diseases, Tenth Revision, Clinical Modification and Current Procedural Terminology codebooks.
- 17. Also called release of information, is designed to manage the processing of requests for protected health information received and processed by the HIM department.
- 18. Requires the user to type in the name or portion of the name of the diagnosis or procedure. This entry generates a list of suggestions from which the coder selects.
- 19. Used by the transcriptionist to type the various documents dictated by physicians.
- 21. The ability to use data and information to achieve its strategy, goals, and mission, or, in short, to realize the value of its information is critical to success with information governance.
- 25. A computer program that uses specific data elements to assign the diagnostic and procedural codes entered into the encoder into the appropriate Medicare severity diagnosis-related group or other diagnosis-related group.