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RHIA Domain ONE
| Question | Answer |
|---|---|
| What is copy and paste? | Responsibility to preserve original copy HIM must be involved corrections process and how functions are enabled and monitor.Policies should established,policy,monitor compliance, enforce policies |
| How do you make corrections and amendments? continue | Facility medical bylaws establish rules and regulations to record content.All entries in health record must be authenticated to identify the author,Paper health record should be ink,Photocopying considered when colored ink or colored forms are used |
| What is quantitative and qualitative? | Quantitative-AKA discharge analysis -IS a review of the HR for completeness and accuracy,done retrospectively,after discharge/conclusion of treatment,If quantitative done while the PT is in the facility it's called CONCURRENT ANALYSIS- |
| What are the different type of signatures? PG 124 | Electronic signatures-electronic process signifying approval terms/documentation in electronic format such as digital signature,image,fingerprint,retinal scan,code or password.Authentication means to prove authorship. |
| What's the difference between structure and unstructured data PG 83 | Data that's organized and easily retrievable,interpreted by traditional databases such as data stored in databases.Unstructured data is data that do not have a predefined data model or not stored in database structure such as documents, emails, images. |
| What is data governance and What does it do? | DG is the enterprise authority that ensures controls& accountability for enterprise data,establishment of decision rights,data policies monitored a formal structure assigned roles,responsibility and accountability. |
| What are the contents management functions that require data governance? | 9 data management domains. Data life cycle management-all data has life-what data is collected,how to be captured,data retention,storage,data access and distribution,standards for data archival and destruction. |
| What is Metadata and master data management? | referred as data about data,structured information used to increase the effectiveness use of data. makes it easier to locate,retrieve,use,and manage such as search engines.providing search/navigation capabilities,4 interoperability,regulatory/legal obs. |
| What is content management and data security? content management functions | encompasses managing structure and unstructured data.To manage data in both forms,policies,standards must be established for storage,retrieval of documents.Developing policies procedures categorization unstructured data electronic,paper |
| What is business intelligence(BI) and Data quality management? content management | Business intelligence-a broad category of applications,techniques for gathering,storing,analyzing,help enterprise users make better business decisions,BI structured data extracted from organization all databases stored in data warehouse. |
| What is terminology and classification management ? Last of the content management | consists of the process for managing the breadth of healthcare terminology,vocabularies,classification system. Ensuring appropriate adoption,maintenance,interoperability,data integrity,mapping among clinical nomencl |
| What is the definition of legal health record? | documents /data elements a healthcare provider may include in response to legally permissible requests for patient info,defined by an organization includes documents and data that determines what it will disclose pursuant to a legal request. |
| What is emergency care? | condition manifesting by acute symptoms of sufficient severity) filed separate or incorporated in MR. MR must be available when the patient is readmitted.record consists of identification data,time of arrival,means of arrival,history, complaint, illness |
| What is ambulatory or outpatient care? | Ambulatory or outpatient care means that patients move from location to location and do not stay overnight,ambulatory can be freestanding clinic,clinic that's part of a larger hospital system,physician or other office. |
| What is behavioral health? | Behavioral health records AKA mental health,psychiatric records,must include diagnostic ,assessment information related to both PT mental conditions and physical health.Medicare (42 CFR 482.61) requires that the inpatients within a psychiatric hospital |
| What is home health services? | National Association for home care and hospice(NAHC) Home care covers many types of services that are delivered at home to PT requiring medical,nursing,therapy or other services. CMS is included in home care health record for the attending physician plan |
| What is hospice care services? | National hospice and palliative care organization(NHPCO) defines hospice care as team oriented approach to expert medical care,pain management,emotional and spiritual support tailored to PT needs (NHPCO 2015),numerous types of settings |
| What is rehabilitation services? | Covers a wide range of services provided to build or rebuild the PT abilities to perform usual activities of daily living.History and physical must be included ,functional history covering the patient functional status before and after injury /illness. |
| What is long term care services? | Long-term care describes the care for extended periods of time to patients recovering from illnesses or injury,ranging from independent living to assistant living to skilled nursing care.record must document a comprehensive assessment treatment plan. |
| What is source oriented health record? | Is the traditional method of maintaining part base health records. Records are organized according to the source,department that rendered the service.Many hybrid health record systems are source oriented and maintained the organization and format of HR |
| What is problem oriented medical record? | Was developed in the 1970s .POMR is comprised of the problem list,database,history and physical examination and initial lab findings,initial plan,test,procedures and progress notes organized so every member in the healthcare team can follow PT treatment |
| What is integrated health record? | Is arranged in strict chronological order.The order of the record is determined by the data the information was entered ,date of service or date report was received rather than by source department.The record gives the sequence of the patient's care deliv |
| What is the SOAP format? | Soap is an a acronym that helps providers remember the systematic decision making process being documented. S stands for subject findings this includes the patient's viewpoint such as symptoms.O stands for objective findings such as labs,test result by DR |
| How long records be maintained? | CMS require health records to be maintained for at least five years according to 42 CF4 482.24b.However retention depends on laws and state regulations.This requirementment includes committee report physician certification,recertification report,radiology |
| How do you develop a retention plan? | HIM must ensure that current HR are retained.inactive records are maintained. Cost effective for storage,health record destruction is in placed,retention periods established.and a committee might be established to review record use,cost and storage space |
| How long should records be maintained? (In depth) | State and federal laws and regulations must be reviewed to e sure that records are mainly rain for the longest length of time period. Many states recommended that patient health record be maintained 10 years following patient discharge or death. |
| What needs to be documented when a record is being destroyed? | Ahima recommends that records be destroyed in such a way that the information cannot possibly be reconstruction (AHIMA 2011) The destruction should be documented and the documentation should include date of destruction,method of destruction shredding |
| What are the MRI (medical record institute )principle of healthcare documentation? | Many steps need to be taken to ensure quality of healthcare .MRI lists essential principles organization should adhere as they establish healthcare documentation. |
| What is MRI accuracy? | System polices and practices should promote accuracy of information throughout all information process, this includes require review to assure accuracy prior to record insertion,including a means to append correction without altering the original |
| How long must medical records be obtain? | 7 years ,depends on state youre in, Federal trumps over all |
| What is MRI completeness? | System polices and practices should identify minimum set of information required to describe an incident,observation or vent. Provide means to ensure information meets legal,regulatory,institutional and other policies.Discourage irrelevant and excessived |
| What is timeliness? | Systems,policies and practices should require and facilitate that healthcare documentation be done during or immediately following healthcare event. Promote rapid system response time for entry as well as retrievability.Provide automatic unalterable time, |
| What is MRI interoperability? | Provide the highest level of interoperability,enable authorized practitioners to capture share and report healthcare information from any system.Support ways to document healthcare Information so that it can be correctly read ,integrated and supplemented |
| What is retrievability? | Support achievement of the worldwide consensus on the structure of information so that the practitioner can efficiently locate relevant information. Enable authorized data searches indexing and mining authenticated |
| What is authentication and accountability? | Uniquely identify persons devices or system that create or generates information and takes responsibility of it's accuracy , timeliness.Required that all information be attributable to it's sources. Requires that unsigned be ready recognizable |
| What is auditability? | Allow users to examine basic information element such as data fields.Audit access and disclosure of protected health information. Alert users of errors,inappropriate changes and potential security breaches,promote use of performance metrics as part of the |
| What is confidentially and security? | Demonstrate adherence to related legislation, regulations,guidelines,and police's throughout the healthcare documentation process and alert users to potential confidentially and security. |
| What are the AHIMA data quality requirements and why are they used? | There are ten characteristics of data quality, in addition to the characteristics, AHIMA published data quality best practices.AHIMA data quality management task force 2012 published a data quality model. The model is used for a framework for management |
| How to use access permissions? | Define and enforce access to data |
| What is data dictionary and why? | A data dictionary exists and each element is defined. The definitions are communicated to all staff. |
| Why would you use standardized format? | Use a standardized format to ensure consistency |
| What regulations are used? | State and federal laws, used all laws , regulations, accreditation standards, and policies are followed |
| How do you practice data integrity with data quality? | By implementing policies and procedures throughout the patient encounters to ensure data integrity. |
| What are the 10 characteristics data quality? | Accuracy,accessibility, comprehensiveness,consistency/reliability, currency definition, granularity, precision, relevancy, timeliness |
| What is accessibility? | Data items that should be easily obtainable and legal to access |
| What is accuracy? | Data that is free from error |
| What is comprehensive? | All required data items are included and ensure that the entire scope of data is collected. |
| What is consistency/ reliability? | Data quality need to be consistent and reliable |
| What is currency? Example | Many types of healthcare data become obsolete after a period of time. A patients admitting diagnosis is often changed by the time he or she is discharged if a clinician needed a current diagnosis. |
| What is definition? Example | Clear definitions should be provided so that current and future data users will know what the data mean,each data element should have a clear meaning and acceptable values. |
| What is granularity? | Data bra hilarity is sometimes referred to as data atomicity which means that the individual data elements cannot be further subdivided. |
| What is precision? | Relates to numerical data , it denotes how close to an actual size, weigh or other standard a particular measurement is |
| What is relevancy? | Data must be relevant to the purpose for which they are collected. Accurate , timely data may be collected about a patient color preferences or choice of hairdresser but are they relevant to patient care. |
| What is timeless? | Timeliness is critical dimension in the quality of many types of healthcare data take, for example, a patient's discharge diagnoses recorded as icd-10-cm codes. These codes must be recorded in a timely manner in order to facilitate reimbursement for healt |
| What are the different types of demographic, clinical, administration, and financial | All health records contain information that is classified into two broad categories, they are administration/demographic data and clinical data. |
| What is administration and demographic information? | Demographic data represents one type of administrative information such as patient's name, address, telephone number, date of birth, next of kin, other identifying information specific to the patient. |
| What is consent to treatment? | Is a consent process where patient agrees to undergo treatments and procedures to be performed. General consent is often part of the admission/intake process that allows the facility to provide routine care, General consent does not replace the individual |
| What is consent use or disclosed protected health record information? | Under HIPPA, at the time of admission to the facility or prior to treatment by the provider. Patients must be informed about to use of individually identifiable health information.The notice of privacy practices must explain and give examples |
| What is consent special procedures? | In cases where the PT is coming to the facility for a specific procedure, an informed consent spelling out exact details of the treatment .just be signed by the patient or legally authorized representatives. |
| What is an advance directive? | Is a written document such as a living will, that states the patient's preferences for care in the event that the patient's condition prevents him from making care decisions. It can also be a form of durable power of attorney naming another person |
| What is a durable power of attorney? | Is a document in healthcare that names someone to make decisions for the patient. This person is called a proxy or healthcare agent and maybe a healthcare agent , provider, family or friend. |
| What is caring connections? | Program of the national hospice and palliative care organization and provides links to information about advance directives in each state. This is helpful because legal processes are primarily dictated by state law. |
| What is acknowledge of receipt of patient's rights statement? | CMS requires that Medicare patients be informed of their rights including to right to know who is treating them , confidentially,visitors, inform about treatment, right to refused treatment, care planning, safe from abuse, privacy and regulations regardin |
| What is property and valuables list? | A list of PT valuables.The list is signed by PT release of responsibility for loss or damage to their personal property.This form comes part of the health record. |
| What is medical history? | Is a summary of the PT illness from his or her point of view.The purpose is to allow the patient authorized representatives to give the practitioner as much background information about the patient illness. Documentation guidelines for HP |
| What are the components of the medical history? And what is chief of complaint? | The medical history has several components including chef of complaint. The chief of complaint is told in the patient's own words or a PT representatives, the chief of complaint is the principle reason the patient is seeking care |
| Components of medical history, what is present illness or history of present illness( HPI)? | This component addresses what the patient feels the problem is and includes a brief description of the duration, location and circumstances of the complaint. |
| Components of medical history, what is the past medical history? | Consists of questions designed to gather information about last surgeries and other illnesses that might have a bearing on patient's current illness. The practitioner asks about childhood and adult illnesses, operations, injuries, drug sensitivities |
| Components of medical history, what is social and personal history? | The social history uncovers information about habits and living conditions that might have bearing ok n the patient's illness such as marital status, occupation, environment tobacco products and psychosocial needs. |
| Components of medical history, what is family medical history? | The questions in this component allow the physician to learn whether the patient's family members have conditions that might be consider genetic such as cardiovascular, cancer, diseases ,or conditions , renal diseases, history of diabetes and health |
| Components of medical history, what is review of systems? | Questions design to cue the patient to reveal symptoms he or she may have forgotten or did not think we're important |
| What is the physical examination? | Actual comprehensive assessment of the patient's physical condition through examination and inspection of the patient's body by the practitioner. The end of the physical examination should include the impression which is a list of the patient's problems, |
| What are some components of the physical examinations? | The physical examination is conducted by observing the patient,Palpatine or touching the patient, tapping the thoracic and abdominal cavities, listening to breath and heart sounds and taking the blood pressure . |
| What is the time frame of the history and physical examination? | The facility must have a policy that establishes a time frame for completing the history and physical. Most facilities set the time frame as within the first 24 hours following admission and require that the history and physical be completed by the DR |
| What is diagnostic and therapeutic orders? | Credentialed practitioner generate orders which direct the healthcare team. Orders can be for treatment, ancillary, medical labs, meds. Orders can change to the PT needs. Orders for tests and service must demonstrate medical necessity |
| Why clinicians authorized to give and receive orders? | Orders must be written by the physician or other credentialed practitioner or verbally communicated to persons qualified and authorized. Medical staff policies and procedures must be state categories of personnel authorized to accept and record orders |
| What are signed on orders? | Orders must be dated and authentication manually or electronically by the treating practitioner responsible for the patient's care who gave the orders. The timing requirements for signatures on orders are governed by state law , facility policies, |
| What are special types of orders ? | Certain categorizes of medication such as narcotics and sedatives have automatic time limit or stop order, this means medication will be discontinued unless the practitioner gives specific order to continue medication. This prevents PT receiving drugs |
| What is do not resuscitate DNR order do and contain? | Contain documentation that the decision to withhold resuscitative service was discussed, when the decision was made, who participate in the decision. This decision is documented in progress notes.Patient's have to consent to CPR unless a DNR order is pres |
| When and who writes a discharge order? | Discharge orders must be in writing and can only be issued by a physician. |
| Where clinical observations orders documented? | Medical services, nursing services, ancillary services , surgical services and organ transplant |
| What are progress notes? | Progress notes are chronological statements about the patient's response to treatment during PT stay in the facility. Each authorized person will enter documentation into the progress note , authenticated and date it and indicate authorship by signing |
| What are consultations reports? | Opinions of physicians with specialty training beyond general board certification such as oncologists,cardiologist or dermatologists.When the attending physician requests a specialist to see the patient the specialist prepares a consultation report |
| What are nursing services? | Nursing documents how orders were carried out, PT vitals, PT response to treatment , PT condition and complaints as well as outcome to treatment. Nursing will use SOAP from problem oriented record format. |
| What is charting by exception? | short hand method of documenting normal finding, based on clearly defined normal, standards of practices, and predetermined criterial for assessments. |
| What is copy and paste? | Copying forward clinical documentation is the process of copying existing text in the record and pasting it in a new destination. Clinicians may use it to save time when updating notes on an existing patient. It is also known as copy and paste, cloning |
| How to make amendments to health record? continue | must be authenticated to identify author, all entries should be in ink, scanning should be consider when color ink forms are used. No erasures or deletions in HR.if a corrected |
| How to make amendments to health record? continue | If a correction must be made in paper MR, one line neatly drawn through the error, leaving incorrect material legible, error initialed and dated so that its obvious a corrected mistake. |
| How to make amendments to health record? continue | correction in EHR the original should be noted and hidden but the incorrect entry should be apart of the record. Original report should be maintain in the HR, Cumulative lab / nursing reports maybe replace with the latest reports. |
| How to make amendments to health record? continue | blank spaces shouldn't be left in nursing/progress notes, should be marked with an x ,so additional info cannot be inserted on paper out of sequence. all blanks on forms should be completed especially consents. |
| How to make amendments to health record? continue | When HR are filed as incomplete(as directed by staff policy)statement should be attached with staff, chair of HIM as specify in policy. |
| How to make amendments to health record? continue | Chart folder labeling/methods of identifying at a glance a particular type of patients such as HIV,drug dx should be discourage to prevent breaches of patient confidentially. |
| What is concurrent analysis? | means the record is analyzed during the pt stay, |
| What is qualitative analysis? | review of quality and adequacy of record documentation, qualitative is more in depth review in health records. |
| How to manage data? life style functions and data governance are? | Establish what data are to be collected and capture, standards for retention and storage, process for data access/distribution, establishing standards for data archival/destructions |
| What is data governance? | The over all management of the availability, usability, integrity ,and security of data employed in an organization or enterprise |
| What is a data life cycle? | made up of series of stages with beginning and end points,data life cycle stages are data planning, data inventory/evaluation, data capture, data transformation/processing,data access/distribution, data maintenance,data archival and data destruction. |
| What are the metadata management functions requiring data governance? | Managing data dictionaries,establishing enterprise strategy, enterprise metadata strategy, developing policies goals /objectives for metadata management,adopting metadata standards, implementing metadata metrics,policy implementation,monitoring |
| What are the components of LHR | LHR in terms of data set to be release in sponse of subpoena by cataloging,using policies, broaden what makes up EHR by considering electronic structured documents, images, audio files,paper documents, should develop and maintain source system matrix, |
| What is data architecture? | an integrated set of specification artifacts ( models and diagrams) used to define data requirements,guide integration, control of data assets, align data investments with business strategy. |
| What are artifacts in data architecture? | developed through architecture data management such as data models,use cases,data flow diagrams / dictionaries,data architecture provides underpinning of an organization info system. |
| What are the functions of data architecture management requiring data governance include? | Establishing standards,policies,procedure for collection,storage,integration of enterprise data and design of info system,identifying and documenting data requirements that support the process of organization. |
| What are the functions of data architecture management requiring data governance include? continue | Developing and maintaining enterprise and conceptual data process models that represent the organization business rules |
| What is ambulatory care? | Provision of preventative or corrective healthcare services on a nonresident basis in a provider office,clinic setting or hospital out patient setting.Health services provided to PT who are not residents in a healthcare facility. |
| What is a designated record set? | a group of records maintained for a covered entity that may include PT medical/ billing records,the enrollment,payment,claims,adjudication,cases or medical management record systems maintained for a health plan,or info used in whole/part care related. |
| What are services provided in an Ambulatory Care setting? | education services provided by a community health clinics,public health departments,primary care,emergency care, ambulatory care,ambulatory surgery, urgent care,school based clinics. |
| What is acute care? | patient receives active but short-term treatment for a severe injury or episode of illness, an urgent medical condition, or during recovery from surgery. In medical terms, care for acute health conditions is the opposite from chronic care/long term care |
| What are some examples of acute care | Acute care services are generally delivered by teams of health care professionals from a range of medical and surgical specialties. Acute care may require a stay in a hospital emergency department, ambulatory surgery center, urgent care. |
| What are the differences between acute care and ambulatory? | acute refers to inpatient care while ambulatory refers to outpatient care. An acute setting is a medical facility in which PT remain under constant care. ambulatory setting a non-medical facility like a school /nursing home, includes medical clinics. |
| What is SOAP A and P | A stands for assessment based on judgement, findings and observations. P stands about plan which stands for methods to be followed in addressing the problems identified. |
| What is data governance? In depth | DG is Enterprise authority ensures control and accountability for Enterprise data through established decision rights data policies includes Enterprise level authority/accountability,established/monitoring data policies/practices,execution of policies |
| What is it important to have a data governance program plan? | A strategic information management plan is developed so that all information management effort are alligned with the organization strategic plan and ensure info management goals and strategies support the organization |
| What is in a Data governance program plan? | IM usually include a description of the business needs for information management this plan includes key objectives,activities and timeline reaching each goal to evaluate plan success.,also ensures compliance with data regulations and mandates. |
| What are the steps for data governance roadmap? | 1) Develop a value statement 2) Prepare a program roadmap 3) Plan and fund the program 4) Design the program 5) Deploy the program 6) Govern the data 7) Monitor the program, measure program effectiveness and report results. |
| What is planning? | Determining what needs to be done and why it should be accomplished is called planning. |
| What is a business case? | Identifying purse and value of program should be first step this referred to business case or value proposal. The business case lays out the benefits and values for the organization. After BC is establish an DG counsel is formed with mission statement. |
| What is data implementation and stewardship? | Overarching authority that ensures policies,standards and accountabilities are in place and enforced for the data management.Normally headed by high level data governance council. |
| What do DG steward functions include? | Advocating for data assets, establishing / approving data strategy and data procedures,communicating,monitoring/enforcing data policy,regulatory compliance,resolving issues,approving projects and coordinating DM organization. |
| What is a DG framework? | is a conceptual structure for classifying,organizing and showing interrelationship among activities used as a guide for taking action to achieve a goal,assists organization in what constitutes DG mission, scope authority and organizational structure. |
| What are the three major part to framework? | 1)Rules and rules of engagement-include policy/standards,controls 2) people/organizational bodies includes data stakeholders/stewards 3) DG process-includes rules/processes for DG program/government. |
| What are the HIE architectural models? | Consolidated or centralized-share resources central data repository,Federated or distributed-consistent databases and inconsistent databases-managed centrally/point to point. Switch-a service enables information exchange-unilateral agreements. |
| What are the HIE architectural models? continue | Patient managed-patient carry their own electronic records direct exchange of data. Hybrid-combination of any of these models. |
| What are the core values of Ahima? | public right to acute /confidential personal health information. Innovation /leadership in advancing health information practices and standards worldwide. Adherence to AHIMA code of ethics. Advocacy / interdisciplinary collaboration with other |
| What is conclusions at terminated of care? | Time of discharge,the physician must summarize PT condition such as beginning of treatment,basic info about test,exam,procedures. Conclusions at terminated of care is called the discharge summary. |
| What is discharge summary? in dept | AKA as clinical resume, provides detail of PT stay while in facility, prepared at discharge,pt transfer or PT expire.States PT reason for stay,gives history,procedures and other findings as well as PT response to treatment.Also instructions care to family |
| What is discharge summary? in dept x2 | Discharge summary also includes information on medications, referrals to other providers, follow up visits and PT final DX. The discharge summary must be authenticated and dated by the physician. |
| Who pronounce the death of a patient? | When a patient expires in the hospital facility requires physician who pronounce death to write a note that gives time and date of death.is required in all cases when PT expires no matter how long a PT is in the facility. Nurse can declare death of PT |
| What's some additional information to discharge summaries? | Discharge summary is not required for PT in hospital less than 48 hours pt usually have short service record.SSR can be used to record history and physical,operative report and discharge summary and discharge instructions. |
| What's some additional information to discharge summaries? continue | a final progress note may suffice in these cases to provide a summary of hospitalization at PT discharge,if PT dies with 48 hours a SSR is INSUFFICIENT complete discharge summary must be prepared,NOT required for normal newborns progress note. |
| When should a discharge summary be completed and how discharge summaries completed with transfer patients? | Discharge summary must be completed with 30 days after discharge,however facilities policies may want a quicker complete date.When PT is transferred physician must complete DS within 24hours. TJC requires DS for transfer PT to another provider. |
| When should a discharge summary be completed and how are discharge summaries completed with transfer patients? continue | Facilities must determine what info goes with patient when transferring level of care when transferring within the same health system the original HR is transfer new orders are written at the receiving initiate of care and a discharge summary is required. |
| What is a discharge plan? | Discharge planning information regarding further treatment of the patient after discharge should be apart of a acute care health record. DS plan begins at admission and must be include PT selfcare ,other needed services.Can be written by nurse SS worker |
| What is template form design? | Well design forms and input screens can facilitate the documentation of care. Forms need to meet facility standards,compatible with imaging and microfilming systems.HIM vigilant to ensure only approve forms are apart of the health record. |
| What is template form design? continue | well design form and templet improves the reliability of data entered on it. should be design to collect info or remind info needs to be collected. Consider number of clicks require to enter info. |
| What are the guidelines for form control? | provide for the development of forms according to established guidelines,control the printing and use of paper forms and integration of a new screen designs or electronic templates. Guide providers in designing forms and templets according to guidelines. |
| What are the guidelines for form control? continue | Guide providers in designing forms and templets according to establishing guidelines. Prevent staff from changing or designing forms that duplicate existing forms or could be combined into other forms/templets. |
| Why is form control critical during EHR hybrid and down time? | FC is critical during hybrid transiting that all forms can be properly scanned and indexed without indexing info cannot be retrieved. updated forms should be made available to staff during downtime. Ensure only approved form are available to staff. |
| What is a unit numbering system? | Most large facilities use a unit numbering system. The patient is assigned a number during the first encounter for care and keeps it for all subsequent encounters. The number is assigned by a computer program. |
| What is serial unit numbering system? | Patient is issued a different number for each admission encounter for care the records for past episodes are brought forward to be filed under the last number issued. creates a unit record of all patient's encounters,not commonly used unit number system |
| What is health record filing system? | Most facilities use numerical filing system for permanent storage of paper based health records. Small facilities such as clinicals use alphabetic filing and larger facilities use numerical filing systems. |
| What is straight numeric filing system? | Records are filed in numerical order according to the number assigned. Most of the file activity is where the most recent numbers have been assigned since records of hospitalization/visits are most used. |
| What is terminal digit filing system? | records are filed according to a three part number made up of two digits pairs. Tertiary, secondary,primary, read right from left. |
| What is health record storage? | Storage is application of efficient procedures for the use of physical filing equipment / storage media to keep records secure and available to those providers/personnel authorized to access them. HIM must protect the original records the duration period |
| What are some record storage suggestions? | Health records should not be subject to damage and difficult to locate such as away from pipes, flammable substances, proper flooring, non temp control storage units are NOT compliant, storage must be clean, free of mold /bugs, |
| What is health record retrieval? | Retrieval is concern when locating records such as signing in and out,HIM is in charge of safeguarding records by ensuring assess as to who needs to knows.HIM must have strict policies inplace for who is checking out records. |
| What do you do if you can't retrieve a record or a loss record? | HIM must be able to prove the loss record was unintentional. Filing area should be audit periodically for rapid access and retrieval,lost report should be attached and those waiting attachments should be sorted/organized to facilitate retrieval |
| According to the Medicare Conditions of Participation, how long must health records be retained and What is CMS medical records retention period for non-medicare managed care program providers? | on the exam sometimes ask about COP..condition of participation..is 5 years, then it willl specifically ask about medicare managed care providers. Which is the 10 yrs. |
| Who owns the information in the health record? | The answer is the patient, the health record is the property of the healthcare facility. However the patient has the right to be informed about the use of his or her protected health information. |
| What is retention? | determine the schedule to be followed to protect and preserve active and inactive records. |
| What is disposition? | process of destroying the record once the retention period has been reached. Establishing policies incorporate state and federal laws,maintaining disaster plan are apart of disposition plan. HIM must adhere to strictest time limit. |
| Who sets accreditation and legal health record retention requirements? | AHIMA recommends retention of health information be based on needs and requirements of facility. TJC asserts the length of health record retention depends on laws, regulations and the use of health records 4 care such as research and education. |
| What are retention requirements for other records? | CMS requires records retain 5yrs this includes reports,radiologist records,home health agency records,long term,labs and other records that document information about claims.Emails,faxes are used for instruction info must be printed and included in record |
| What are retention requirements for other records? continue | Strips, EKGs, EEGs, Fetal monitors,stress tests, echos do not have to be kept within the physical record but must be retrievable for long legally required. Fetal strips are apart of mother record but should maintain length of time for minor record. |
| What are retention requirements for other records? continue | CT / MRI are not consider permanent health records hard copy must placed in patient's health record for full retained period required by law. CFR 900.12 mammograms must maintain for 5 to 10 years depending treatment,state law may require 20 to 30 yrs |
| How long should employee occupational records be obtain? | According to OSHA occupational safety and health administration requires records of employees with occupational exposure to be maintain for duration of employment plus 30years for statues and legal. |
| What are the steps in developing a record retention program? | Conduct inventory of facility records, determine format and location of record storage, assign record retention period,destroy records no longer needed. |
| What is example of primary data source? | The health record is considered a primary data source because it contains information about a patient that has been documented by professionals who provide care or services to the patient. |
| What is an example of secondary data source? | Data taken form primary record and entered into registries and databases are consider secondary data, secondary data provides info that is not easily available by looking at individual health records, identify patterns and trends. |
| What is patient identifiable data? | The health record consists of patient identifiable data, every fact recorded in the record related to patient is patient identifiable. |
| What is aggregate data? | Secondary data is considered aggregate data. include data on groups of people or patients without identifying any particular patient individually. Example is statistic on ALOS. |
| What internal and external users of data? | Internal users of secondary data are individuals located within the healthcare facility including medical medical staff. External users of patient data are individuals and institutions outside the facilities. |
| What is an index? | is simply a report from a database that enables health records to be located by DX, procedure or physician. computerized reports available from data included in databases routinely maintained in the healthcare facility. |
| What is a master patient index? | MPI contains patient identifiable data such as name, address, DOB, dates of hospitalizations or encounters, name of attending, important source of MRN for facility to quickly retrieve ,helps avoid dup record number. enter info of admission,pre-admisison. |
| What is a disease index? | is a listing in diagnosis code number order for patients discharged from the facility during a particular time period,each PT diagnoses are converted into ICD 10, enter in system, so records can be retrieved by DX, may include attending DR, the discharge |
| What is a physician index? | is a listing of cases in order by physician name or physician identification number, nclude PT health record |
| What is a operation index? | similar to disease index except it is arrange in numerical order by the patient's CPT / procedure code or ICD , surgeon may be listed instead of attending. |
| What are registries? | different from indexes in that they contain more extensive data. Registries require more extensive data from the PT medical record. each registry must define the cases that are to be included. |
| What is case definition? | Registry must define the cases that are included. Example , all cases admitted with a certain DX |
| What is abstracting? | The process of review the patient healthcare record and entering the required data elements into the database. done on a abstract form then entered into the database. Birth defects registries often download in vital system. |
| What does national hospital care survey from the national center for health statistics do? | hospitals and physicians send information in electronic format to the registry or database known as national center for health statistics in electronic format from state database. |
| Does the patient have to sign a authorization form for release of protected health information PHI to be included in registry? | required reporting and does not require pt authorization for release. |
| What is some additional information about data security and confidentiality ? | Data maybe release to internal users such as physicians for research without pt consent, external users such as American College of surgeons collect aggregate data from facilities PT autho is not required. |
| What is some additional information about data security and confidentiality ? x 2 | Info about PT that include data registry or other secondary data and reported to outside entities must include notice of privacy practice given to each PT through this PT are made aware data about them being reported. |
| What is some additional information about data security and confidentiality ? x 3 | Not all registries are covered under HIPPA if they do not bill for patient acre services. example Central registries so general norms for data security and confidentiality should be followed. |
| Why is data security important? | registries/secondary databases must ensure the security of the information that they maintain a number of methods such as passwords, lost of data is important because more often lost computer malfunction or computer viruses |
| How should employees practice confidentially? | All employees working with PT data should receive training on confidentiality and required to sign a yearly statement indicating they receive training understand implications of failure to comply. |
| what are Best practices for data quality requirements for information systems? | Access permissions to enforce access to data,data dictionary exists and data element is defined,Use standardized format to ensure consistency,all laws/regulations, policies r followed,Data integrity policies procedure PT encounter 4 data quality. |
| What is data dictionary? | is a set of descriptions of data items in a data model for reference for systems users |
| What are the two general types of data dictionaries? | DBMS database management systems a developed in conjunction with development of a specific database.Modern DBMS have built in data dictionaries that go beyond |
| What are some trends in collection of secondary data? | is the increase use of automated data entry, databases/registries are more commonly using data already available in electronic form rather than manually abstracting all data. AHIMA practice brief who can do what to which data and under which circumstance |
| What are the requirement for H/P according to TJC? | H&P be completed no more than 30 days before or 24 hours after admission prior to procedures services. outpatient procedures /same-day admissions when the H&P is completed within 30 days prior to the procedure,update is required after admission |
Created by:
Lclarey