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Health Information Management

When someone is DESCRIBING how they are feeling. You cannot see it. Example: Patients/and or family telling you SUBJECTIVE
When you can see something for yourself. Measuring vital signs, a bump on their head, high fever, etc OBJECTIVE
Most important tool Patients Health Record
Completed report of Health Records end up as paper file OR Electronic Health Record (EHR)
EHR stands for Electronic Health Record
Order of Health Record: *Starts with Phone Call *Medical Administrated Assistant gathers info (subjective/objective) *Medical Transcriptionist types report - paper or Electronic Health Record (EHR) *Coder identifies disease/injury -Which codes to Order of Health Records
Basic facts about a patient Patient Demographics
Patient Demographics and personal info can only be obtained in writing False
Foundation of the medical record is formed only of Demographic info False
Job as Medical Coder: *Use patients Health Record to find Diagnosis - reason for visit determined by Physician - Translate Diagnosis into standardized codes for billing. *Identify the reason for encounter. Examine Health Record for primary Diagnos Job as a medical coder
This lists codes in order of A-Z The Tabular List
A person who participates directly or indirectly in providing healthcare services to a patient. Physician medical secretary, nurse, physician assistant, nurses aid, admissions clerk, lab/radiology tech Healthcare Worker
Demographics include basic information such as *Name *address *telephone # *gender *date of birth *insurance/billing info
An important factor for establishing/managing healthcare Patient Information: age gender insurance medical history
Different methods used to obtain patient info: Commonly known as Subjective and Objective FIRST method - asking questions, obtaining descriptions, interviewing, filling out forms (Subjective) SECOND method - Observing, examining, recording results (Objective
Dependent on the mind or on an individual's perception for its existence. SUBJECTIVE
Factual or not influenced by personal feelings or opinions. OBJECTIVE
Info provided by patient/family describing how they feel, what happened, where it hurts Example: my head hurts, I feel nauseated SUBJECTIVE
Data collected from observation/exam. Looking, testing, touching. Example: Cut on the head, 100 temp OBJECTIVE
Medical Records are filled with *Demographics *Patient supplied info *Subjective/Objective statements *Results Recorded
First step in coding 1.)Identify the reason for an encounter with the physician -Find Diagnosis as it is documented in the Health Record -In patients HR, click the part of the documentation that documents Diagnosis -IMPRESSION section of Health Re First steps in coding
Collecting patient information: *Common practice to receive follow up calls *Those undergoing same-day/outpatient surgery - call a day or two after treatment *Query about any complications *Reminded of postoperative or postcare instructions Examp Collecting patient information
A series of definitons collected on all hospital inpatients. Example: Principal diagnosis, procedure, discharge date, discharge status To collect information at discharge standard abstracting systems are used. *Coding info is entered into Uniform Hospital Discharge Data (UHDDS)
UHDDS stands for Uniform Hospital Discharge Data
Subjective or Objective: Patient feels nauseated and has feelings of disorientation. Subjective
Subjective or Objective: Patient has a temperature of 101.2 degrees F. Objective
Subjective or Objective: Patient has a burst left eardrum. Objective
Patient feels pain in their left ear. Objective
True or False. The UHDDS is used in the hospital inpatient setting to collect data on discharged patients. True
True or false. Abstracted patient information is used only internally. False
Created by: CodiLynn
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