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HIT Chapter 4

Health information management by Michelle A Green & Mary Jo Bowie

Includes medical staff-approved abbreviations, acronyms and symbols that can be documented into a patients record. Abbreviation List
Clarifying or to add additional information about previous documentation or enter a late entry(out of sequence) PURPOSE is to provide additional information NOT to change it Addendum
Administrative data
Facilities must retain records for a time period in addition to the retention law Age of consent/ Age of majority
Provide behavioral health, home health, hospice, outpatient, skilled nursing and other forms of care Alternate Care Facilities
Off-site storage, microfilm or optical imaging Alternative Storage method
Correcting documentation in the patient record. The only person authorized to correct an entry is the author of the original entry. Amending the patient record
Records placed in storage and rarely accessed Archived Records or Inactive records
Judgement, opinion, or evaluation made by the health care provider (ex. acute migraine) Assessment (A)
Was developed by ASTM. Intended to complement standards developed by other organizations ASTM E 1762- Standard Guide for Authentication of Healthcare Information
A technical control created by an EHR system and consists of a listing of all transactions and activites that occurred Audit trail
All patient record entries need this, it means that an entry was signed by an author Authentication
Involves a provider authenticating a dictated report prior to its transcription Auto- authentication
Chart deficiencies
The oldest information is filed first in a section Chronological date order
Clinical Date
Is a form of authentication by an individual in addition to the signature by the original author of an entry Countersigniture
Contains a minimum set of data to be collected on every patient: chief complaint, present conditions and diagnoses, social data, past, person, medical and social history, review of symptoms, physical examination, and baseline laboratory data Database
Deficiency Slip
The Joint Commission requires patient records to be completed 30 days after the patient is discharged Delinquent record
Divide the total # delinquent records by # of discharges in that period Delinquent record rate
patient identification information; Patient's name, D.O.B, place of birth, mother's maiden name, S.S # Demographic data
Plans to learn more about the patients condition and the management of the conditions. Diagnostic/management plans
Digital archive
Created by using public key cryptography to authenticate a document or message Digital signature
(CPR's) Computer based patient records include electronic and/or digital characters and signatures that are permanently stored on a disk. EHR- Electronic Health Record
A generic term that refers to the various methods by which an electronic document can be authenticated Electronic signature
Hospital Ambulatory care record
Documents the care and treatment recieved by patient admitted to the hospital Hospital inpatient record
Documents services received by a patient who has not been admitted to the hospital overnight and includes ancillary services, emergency department services and outpatient surgery Hospital outpatient record (Hospital Ambulatory Care record)
Inactive records
Collects information about a potential compensable even Incident report
Contains clinical information created by researchers Independent database
Process of recording representations of human thought, perceptions or actions in documenting patient care (handwriting, speaking, typing, touching a screen, pointing and clinking on words/phrases) Information capture
Describes actions that will be taken to learn more about the patients; condition and to treat and educate the patient, according to three categories: diagnostic/management plan, therapeutic plans, patient education plans Initial plan
Arranges reports in strict chronological date order Integrated record
Magnetic degaussing
To maintain patient records in a paper format Manual record
Involves keyboarding medical information dictated by a provider Medical transciption
Listens to dictated information and keyboards the report. Medical transcriptionist
Refers to the use of wireless technology to enable health care professional to make better-quality decision while reducing the cost of care and improving convenience to caregivers mHealth
Photographic process that records the original record on film, with the film image appearing similar to a photograph negative microfilm
Documents the patients history, current medication, and vital signs on a variety of nursing forms, including nurses' notes, graphic charts and so on nursing assessment
Observations about the patient, such as physical findings or lab or X-ray results (chest x-ray negative) objective (O)
Used to store records at a location separate from the facility Off-site storage/Remote storage
Plans to educate the patient about conditions for which the patient is being treated Patient education plans
serves as business record for a patient encounter ; contains documentation of all health care services to a patient Patient record
The person who has legal responsibility for the patient Patient's represetative
Use administrative and clinical data, documented in physicians office Physician office record
Diagnostic, therapeutic, and educational plans to resolve the problems (ex. patient to take tylenol as needed for pain) plan (P)
An accident or medical error that results in personal injury or loss of property (PCE)- Potentially compensable event
Incorporates patient registration, testing, and other services into one visit prior to inpatient admission and the results are incorporated into the patients record. (xrays, ekg, Lab testing) (PAT)- Preadmission testing
Records that document patient care provided by HCProfessionals that include : Original patient record, X-rays, Scans, EKG's and other documents of clinical findings primary sources
Acts as a table of contents for the patient record because it is filed at the beginning of the record and contains a list of the patient's problems problem list
More systematic method of documentation, 4 components : Database, Problem list, Initial plan, Progress notes. Developed by Lawrence Weed. (POMR)/ (POR)- Problem oriented medical record
Is obtained from the attending physician and is the diagnosis upon which patient care is based Provisional diagnosis
Uses an algorithm of 2 keys. One for creating the digital signature by transforming data into a seemingly unintelligible form and the other to verify a digital signature and return the message to it's original form. public key cryptography
Remove inactive records from the file system Purge
record destruction method
A schedule that outlines the information that will be maintained, the time period for retention, and the manner in which information will be storedb record retention schedule
remote storage
The construction of a healthcare document, consists of the formatting and/or structuring of captured info report generation
Length of time a facility will maintain an archived record. Based on fed and state laws. retention period
The most current document is filed first in a section of the record reverse chronological date order
Contain data abstracted from primary sources of patient info : indexes and registrars, committee minutes, incident reports and so on secondary sources
Each source of data is in the inpatient record has a section that is labeled. ''Subdivided into sections'' sectionalized record
Paper record that contains copies of original records and is maintained separately from the primary record shadow record
A document maintained by the Health Info Department to identify the author by full signature when initials are used to authenticate entries signature legend
A provider whose signature the stamps represents must sign a statement that she or he alone will use the stamp to authenticate documents. Can be allowed in a facility, if allowed by state and federal law. signature stamp
A physician who practices alone solo practitioner
Maintains reports according to source of documentation (ex. documents from nursing staff are in nursing section report, Radiology reports in a radiology section) (SOR)- Source oriented record
Time period during which a person may bring forth a lawsuit statue of limitations
Patients statement about how she feels, including symptomatic information (ex. headache) subjective (S)
Is a verbal order taken over the phone by a qualified professional from a physician (should be used in emergency situations) (T.O) - Telephone order
specific medications, goals, procedures, therapies, and treatments used to treat the patient therapuetic plans
Is documented when a patient is being transferred to another facility, and it summarizes the reason for admission, current diagnoses and medical information, and reason for transfer transfer note
Also known as a verbal order. Is an order where the physician dictates an order in the presence of a responsible person (emergencies only) (V.O)- Voice Order
What's on each page of physician record? facilities name, mailing address, phone #
Method's for authentication Written signatures, Countersignatures, Initials, Fax Signatures, Electronic signatures, Signature stamps
Hospitals must have a written policy to identify the staff members authorized to recieve and record verbal orders. Must include the date and names of individuals who gave, received, recorded and implemented the orders.
How to Amend a patient record? 1. Draw a single line through the incorrect infom making sure it still remains visible 2. Date, Time and sign the corrected entry 3. Document a reason for the error (ex. ''made in error'', ''entry made in wrong chart''. 4. Enter the correct info
Tidbit System should store both the original and corrected entry as well as a record of who documented each entry.
1.Document the word 'addendum' 2. Current date and time, as well as original date and time for reference. 3. Authenticate the addendum. 4. State the reason for documenting the addendum. 5. Steps for ammendum
Created by: s.fitzpatrick410