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Chapter 5


DEEDS Data Element for Emergency Department Systems
HEDIS Helath Plan Employer Data and Information System
MDS Minimum Data Set
MPI Master Patient Index
OASIS Outcome and Assessment Information Set
RAI Resident Assessment Instrument
RHIO Regional Health Information Organization
UCDS Uniform Clinical Data Set
SOAP Subjective Objective Data Plan
Acute care patient record Usually concerned with one stay/episode
Outpatient medical record Usually limited to one group/clinic
Data Means both computer information and information in health record. Data refers to facts
Information Processed data in a useful form that conveys meaning
Knowledge A combination of rules, relationships, ideas and experience
Patient Health Record Primary legal record documenting health care services provided to a person in any aspect of the health care system; Repository of information about a single patient Condition of patient’s health Care and treatments the patient received Outcome of car
Patient Health Record Generated by health care professionals as a direct result of interaction with a patient or with individuals who have personal knowledge of the patient
Primary Records Used for patient care; information gathered from patients and their providers, additional information from devices, dx tests
Secondary Records Created after patient care by the analysis, summarization, or abstraction of information from primary records; Used for reimbursement or insurance claims, research, government agencies, quality improvement
Demographic Data Collected upon initial registration, includes name, address, phone numbers, billing info; called face sheet in paper system
Physical Exam is also called: SOAP note (progress notes and physcian's office)
Clinical Data Medical Hx, Physical exam, dx and therapeutic orders/reports, dx images/reports, pre-op and operative reports, referral consultation reports
Referral consultation reports must include: information about the source and reason for the request, evidence that the consultant reviewed the patient’s medical record and examined the patient, documentation of pertinent findings, opinions, and recommendations
SOAP Notes Subjective - Pts description of symptoms and chief complaint; Objective - findings of physical and dx tests; Assessment - Physicians dx; Plan - Physicians orders and plan of care for tx
Standard Data Elements Improves interoperability, defined by NCVHS; Collection of data elements determined to be minimum necessary for particular purpose; Usually represent minimum list of data, elements that must be collected
NCVHS National Committee on Vital Health Statistics
RHIO Implementation Issuses Technical issues related to interfacing with multiple, unrelated healthcare systems; Economic issues related to who bears cost of networking, interface programming, and maintenance of translation and MPI systems, political/ownership issuses
Real-time telemedicine Requires presence of all parties at same time; Challenges: different time zones, state laws
Store and forward telemedicine Allows one party to send information that is saved, then reviewed; Challenges: delays when additional information, tests, response needed
Teleradiology transmission of diagnostic images from one location to another, usually to have images “read” by radiologist
Telemonitoring Transmission of information from devices that allow doctors to study multiple measurements of vital signs or tests in course of patient’s normal daily activity
Advantages of E-visits: secure msg transmission, creates documented medical records with symptom information, handled by a doctor on call; May be reimbursed as legitimate visit by Blue Cross/Blue Shield plans and other private insurance carriers
Created by: RBarnes86