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HIT Objectives Ch.4

Objections Ch.4

Differentiate among various types of patient records Hospital Inpatient Record- documents the care and treatment recieved by a patient admitted to the hospital. Hospital Outpatient Record-docuements services recieved by a patient who has not been admitted to the hospital overnight.
Summarize the purpose of the patient record Serves as the business record for a patient encounter
Provide examples of adminstrative and clinical data Administrative data-includes demographoc,socioeconmic, and finacial information. Clinical data- includes all patient health information obtained throughout the treatment and care of the patient.
Delineate provider documentation responsibilities Must be trained and competent in the fundmental documentation practices of the organization and legal documentation standards. Only authorized individuals may make entries in the medical records.
Summarize the development of the patient record Patinet records are develpoed from many sources. Preadmission testing(PAT)- incorpates patient registration,testing, and other services into one visit prior to inpatient admission, and the results are incorporated into the patient's record.
Explain the correct method for correcting documentation The author of the original entry, should fix the error.
Distinguish between manual and automated record formats Manual- paper based format. Automated-is all done electronicly, saves time.Also improves record access, control, and elimates papar usage
Discuss the importance of authentication of records Means an entry is signed by the author(provider).Only the author of that entry can authenticate that entry, thus establishing that entry is accurate and has been verified by the auhtor.
Compare alternative storage methods Off-Site or remote storage- is used to store records at a location separte from the facility. Microfilm- is a photographic process that records the original paper record on film. Optical Disk Imaging-Systems are capable of scanning a paper based record.
Summarize patient record completion responsibilities Responsibilty for completing the patient record resides with the govering body, facility adiminstration, attending physican, other health care professionals and the health information department.
Created by: Courtneey