COMPREHENSIVE REVIEW GUIDE FOR HEALTH INFORMATION RHIA & RHIT EXAM PREP 9781284027648_FMxx_i_x.indd 1 SECOND EDITION Carla Tyson-Howard EdD, MHA, RHIA Chair, Health Information Technology Department Houston Community College Shirlyn C. Thomas MEd, RHIA Executive Director, Holistic Community Development Corporation Adjunct Instructor, Health Information Technology Department Houston Community College
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Contents about the authors acknowledgments vii ix chapter 1 Introduction 1 How to Use This Review Guide 1 A Word About Soft Skills 10 Study Tips 11 Test-Taking Tips 12 chapter 2 Health Data Management, Health Services Organization, Delivery and Reimbursement Methodologies 15 Definition, Purpose, Uses, and Users of the Health Record 15 Format of the Health Record 16 Basic Principles of Health Record Documentation 17 Content of the Acute Care Health Record 18 Record Content for Alternative Healthcare Sites 19 Data Quality Monitoring 20 Forms Design 22 Healthcare Data Sets and Databases 24 Data Quality and Technology 24 Data Access and Retention 27 Secondary Health Information Data Sources 30 Health Information Management Organizations and Professionals 32 Health Services Organization and Delivery 33 Regulatory Agencies 44 Clinical Vocabularies 46 Financing Healthcare Services: Reimbursement Methodologies and Systems 47 Practical Application of Your Knowledge 55 Test Your Knowledge 67 chapter 3 Healthcare Privacy, Confidentiality, Legal, and Ethical Issues 73 Introduction to the Legal System 73 Health Record Requirements and Retention Guidelines 76 iii 9781284027648_FMxx_i_x.indd 3
Contents Chapter Title Confidentiality, Consent, and Security of Health Records 80 Laws and Regulations Regarding Health Records 82 Release of Information and Subpoenas 82 Healthcare Privacy 83 Health Insurance Portability and Accountability Act (HIPAA) of 1996 87 Health Record Documentation 94 Health Records in Court 94 Negligence and Malpractice 98 Computer-Based Health Records 101 Ethical Issues for Health Information Practitioners 102 Freedom of Information Act 103 Minimum Necessary Standard 103 Patient Protection and Affordable Care Act (PPACA) 103 Amendment to HIPAA Privacy, Security, Breach Notification, and Enforcement Rules 103 Right to Request a Restriction of Uses and Disclosures 113 Individuals Right of Access to PHI 113 Fundraising 114 Marketing 114 Sale of PHI 114 Decedents, 50-Year Release 115 Decedents, Disclosures to a Family Member/Others Involved in Care 115 Student Immunization in Schools 115 Expansion of Rule s Application: Definition of Business Associate 115 Security Rule 116 Notice of Privacy Practices 117 Modifications to the HIPAA Privacy Rule Under GINA 117 Legislation/Regulation Trends Impacting HIM 117 Practical Application of Your Knowledge 130 Test Your Knowledge 141 chapter 4 Healthcare Statistics, Research, and Epidemiology 147 Statistics 147 Vital Statistics 148 Analysis of Hospital Services 149 Presentation of Data 152 Common Healthcare Statistical Measures and Tests 156 Research 164 Epidemiology 165 Practical Application of Your Knowledge 167 Test Your Knowledge 174 Formulas for Commonly Computed Healthcare Rates and Percentages 186 chapter 5 Quality Management and Performance Improvement 189 Clinical Quality Assessment 189 Utilization Management 213 Risk Management 219 Credentialing 222 Accreditation 234 iv 9781284027648_FMxx_i_x.indd 4
Chapter Contents Title Joint Commission Accreditation Status 234 Licensure 235 Certification 235 Compliance 235 National Patient Safety Goals 235 Environment of Care 236 Legal Implications of Performance Improvement 236 Practical Application of Your Knowledge 238 Test Your Knowledge 252 chapter 6 Information Technology and Systems 259 Timeline for the Evolution of Health Information Systems 259 Information Technology 259 Information System 260 Design and Development of Health Information System (HIS) 261 Classification of Healthcare Information Systems 266 Database Management System 266 Information Security 272 Emerging Technologies 274 Internet Technologies 274 Electronic Health Records 276 Information Resources Management (IRM) 278 Role of Health Information Manager in Information Systems 279 Fundamentals of Health Workflow Process Analysis and Redesign 279 Migrating to an Electronic Health Record 281 Configuring Electronic Health Records 282 Practical Application of Your Knowledge 290 Test Your Knowledge 297 chapter 7 Biomedical Sciences 303 Common Drug References 303 Common Pharmacology Abbreviations 314 Common List of Lab Values 315 Test Your Knowledge 335 chapter 8 Clinical Classification Systems 339 ICD-9-CM Official Guideline for Coding and Reporting 339 Conventions for the ICD-9-CM 339 General Coding Guidelines 341 The ICD-10 Transition: An Introduction 345 ICD-10-CM and ICD-10-PCS Official Guideline for Coding and Reporting 346 Documentation and Coding Quality 346 Nomenclature and Classification System 346 Why We Code 346 ICD-10-CM and ICD-10-PCS 346 Format of ICD-10-CM Coding Book 347 Conventions for the ICD-10-CM 353 v 9781284027648_FMxx_i_x.indd 5
Contents General Coding Guidelines 357 CPT-4 and HCPCS 360 Practical Application of Your Knowledge 363 Test Your Knowledge 367 Mock Medical Records 371 chapter 9 Organization and Management: Human and Financial Resources 437 Management 437 Leadership 447 Communication 449 Conflict 450 Solving Problems 450 Human Resources Management (HRM) 451 Strategic Management 454 Project Management 454 Work Design and Performance Improvement 455 Financial Management 459 Practical Application of Your Knowledge 465 Test Your Knowledge 480 references 485 answer key 489 index 501 vi 9781284027648_FMxx_i_x.indd 6
About the Authors Carla Tyson-Howard, EdD, MHA, RHIA Chair, Health Information Technology Department Houston Community College Shirlyn C. Thomas, MEd, RHIA Executive Director, Holistic Community Development Corporation (CDC) Galveston, Texas Adjunct Instructor, Health Information Technology Department Houston Community College Contributing Authors Fannie C. Hawkins, EdD, CPHQ, RHIA (Chapter 8: Clinical Classification Systems) Program Director, Health Information Management Department Texas Southern University Jeannie Helton, RHIT (Chapter 8: Clinical Classification Systems) Adjunct Faculty, Health Information Technology Department Houston Community College Casandra Johnson, RHIT, CCS (Chapter 8: Clinical Classification Systems) Health Information Manager Park Plaza Hospital Bunmi Ogunleye, MSHEd, CHES, RHIA (Chapter 3: Healthcare Privacy, Confidentiality, Legal, and Ethical Issues; Chapter 5: Quality Management and Performance Improvement) Health Information Manager Harris Health System Adjunct Instructor, Houston Community College vii 9781284027648_FMxx_i_x.indd 7
About the Authors Irma Rodriguez, MEd, RHIA, CCS (Chapter 2: Health Data Management, Health Services Organization, Delivery and Reimbursement Methodologies) Chair, Health Information Technology Department South Texas College McAllen, Texas viii 9781284027648_FMxx_i_x.indd 8
Acknowledgments I am grateful to G-d for giving me the idea, inspiration, and energy to codevelop this review guide with my sister-partner, Shirlyn Thomas. It is a labor of love to my students and health information students around the world. I hope that this review guide brings clarity and focus to your studies and exam preparation. I express gratitude to my mentors, Linda Johnson and Tella Williams, for guiding me in the health information field. Thank you also to Debora Butts for reviewing and providing input on the text while under construction. I thank the co-authors for sharing their knowledge, wisdom, and expertise. I acknowledge Houston Community College for supporting faculty in the use of technology to make the teaching and learning process easier. In memory of my father, Carl, I thank him and my mother, Odell Tyson, for instilling in me the importance of education. Thanks to my sister, Cassandra Tyson, and my friend Elizabeth Hoover for countless hours of reviewing and referencing material. Finally, I acknowledge my handsome husband, John Howard, whose encouragement and endless love are priceless. Carla Tyson-Howard No one is or becomes without the help of others. I would like to express my sincere gratitude to the others in my life who have contributed in various ways to make this product a living instrument to help others. To God and my Lord and Savior, for creating me in your image and your likeness and for equipping me with all that was needed to complete your idea. To Carla, for being a conduit of the idea and allowing me to share a part of making the lives of others better and for being one of my greatest teachers. To my mother, who has given me a genetic transfer of determination and tenacity. To my wonderful and precious husband, who became whatever I needed in the toughest parts of the process and is always a source of strength. To my children, LaToya, T.K., and Trae, who are my inspirations and whose faces I reflect on when the going gets tough. To my grandson Prince Manuel, who is the joy of my heart. To my sisters, Deborah and Kim, who are parts of the foundation on which I stand. Thanks for your never-ending support. To all of the contributing authors, thank you for co-laboring with Carla and I to make this a superior learning tool. Shirlyn Thomas ix 9781284027648_FMxx_i_x.indd 9
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