HIT 100
Mid Term Study Guide
Spring 2013

|EMTALA |Emergency Medical Treatment and Active Labor Act “Anti-Dumping Act” |
|H&P |History and Physical |
|Discharge Summary |Required when a patient is discharged from the hospital. |
|Death Summary |Required when a patient expires while an in-patient |
|Clinical Resume |Discharge Summary |
|24hrs |H&P should be in the patient record |
|72 hrs |Coroner’s Preliminary Report is due in the patient record |
|8 hrs or less |If patient is having surgery or in an emergency |
|Retention period for medical records of minors |The age of majority plus 12 yrs |
| 10.CARF |Commission on accreditation of Rehabilitation Facilities |
| IOM |Institute of Medicine |
| WHO |World Health Organization |
| Advance Directive | |
| Living Will | |
| Palliative care |Not curative, to make comfortable |
| IHS |Indian Health Services |
| HHS |Health and Human Services |
| CAHIIM |Commission on Accreditation of Health Informatics and Information |
| |Management |
| AHIMA |American Health Information Management Association |
| CHIA |California Health Information Association |
| SCHIA |So Cal Health Information Association |
| CRNA |Certified Registered Nurse Anesthetist |
| ATD |Admissions, Transfers and DIscharges |
| Centralized vs decentralized | |
| DSM-4 |Diagnostic and Statistical Manual-Forth Edition |
| ICD |International Classification of Diseases |
| ICD-9-CM