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Purpose & Function of Health Record

professional org. that establishes standards against which healthcare org. are measured & conducts periodic assessments of performance of individual healthcare org. accreditation organization
data extracted from individual health records & combined to form deidentified info about groups of patients that can be compared & analyzed aggregate data
credentialed healthcare workers who is not physician, nurse, psychologist, or pharmacist allied health professionals
division of DHHS responsible for developing healthcare policy in US & administering Medicare program & federal portion of Medicaid program Centers for Medicare & Medicaid Services (CMS)
healthcare worker responsible for assigning numeric/alphanumeric codes to diagnostic/procedural statements coding specialist
legal/ethical concept establishes healthcare provider's responsibility for protecting health records & other personal/private info from unauthorized use/disclosure confidentiality
dates, numbers, images, symbols, letters & words that represent basic facts and observations about people, processes, measurements, & conditions data
extent to which healthcare data are accessible whenever/wherever they are needed data accessibility
extent to which data are free of identifiable errors data accuracy
extent to which healthcare data are complete data comprehensiveness
extent to which healthcare data are reliable data consistency
extent to which data are up-to-date data currency
specific meaning of healthcare-related data element data definition
level of detail at which attributes & values of healthcare data are described data granularity
extent to which data have values they are expected to have data precision
managerial process ensuring integrity of org. data during data collection, application, warehousing & analysis data quality management
extent to which healthcare-related data are useful for purpose for they were collected data relevancy
concept of data quality that involves whether data is up-to-date & available within useful time frame data timeliness
numeric/alphanumeric characters used to classify & report diseases, conditions & injuries diagnostic codes
electronic record of health-related info on individual that conforms to nationally recognized interoperability standards & that can be created, managed, & consulted by authorized clinicians & staff across more than one healthcare org. electronic health record (EHR)
paper/computer-based tool for collecting & storing info about healthcare services provided to patient in single healthcare facility health record
health record that includes both paper & electronic elements hybrid health record
factual data that have been collected, combined, analyzed, interpreted, &/or converted into form that can be used for specific purpose information
system of health record org. in which all paper forms are arranged in strict chronological order & mixed w/forms created by different departments integrated health record format
electronic record of health-related info on individual that conforms to nationally recognized interoperability standards that can be drawn from multiple sources while being managed & controlled by individual personal health record (PHR)
health record documentation approach in which physician defines each clinical problem individually problem-oriented health record format
numeric/alphanumeric characters used to classify & report medical procedures/services performed for patients procedural codes
org. that performs medical peer review of Medicare/Medicaid claims, incl. review of validity of hosp. diag./procedure coding info; completeness, adequacy, & quality of care; & appropriateness of prospective payments for outlier cases/nonemergent use of ER quality improvement organization (QIO)
compensation/repayment for healthcare services reimbursement
means to control access & protect info from accidental/intentional disclosure to unauthorized persons & forms of unauthorized alteration, destruction, or loss security 1
system of health record org. in which info arranged according to patient care dept. that provided care source-oriented health record format
insurance co. or healthcare program that reimburses healthcare providers &/or patient for delivery of medical services 3rd-party payers
specially trained typist who understands medical terminology & translates physicians' verbal dictation into written reports transcriptionist
planned, systematic review of patients in healthcare facility against care criteria for admission, continued stay, & discharge utilization management organization 1
physical therapist, dietitian, social worker, occupational therapist examples of allied health professionals
prior to 2001 Centers for Medicare & Medicaid Services (CMS) was called Health Care Financing Administration (HCFA)
data __ & __ are interchangeable currency; timeliness
depending on the setting a health record can also be called patient, medical, resident, or client record
until 2002 quality improvement organization (QIO) was called peer review organization
phys. protection facilities & equip from theft, damages/unauthorized access; collectively-policies, procedures/safeguards designed to protect confidentiality of info, maintain integrity & availability of info systems, & control access to content of system security 2
collection of systems & processes to ensure facilities & resources, both human/nonhuman, are used maximally & are consistent w/patient care needs utilization management organization 2
health record is __ __ for data & info about healthcare services provided to individual patient principle repository
modern __ __ for health record did not begin until early 20th-century documentation standards
records of acute care patients who receives services as hospital inpatients are often called patient records
physicians & their office personnel typically called the health record of a patient medical record
records of patient in long-term care facilities are often called resident records
facilities that provide ambulatory behavioral health services sometimes refer to the health record as client record
paper-based health records, especially in hospital settings, are sometimes called charts
primary purpose of health record is to __ & __ patient care services document; report
data represents __ & information represents __ facts; meaning
management of health record systems is primary responsibility of health information management (HIM) professionals
future of HIM professional practice will be based on __ collection, storage, & analysis of healthcare info created & maintained in __ EHR electronic; interactive
PHRs may be __ or __ paper-based; computerized
is computerized, contains complete health history of individual, & is accessible online to anyone that have been given access by individual ideal PHR
currently there is no __ __ for individual to maintain PHR legal mandate
recommended that PHR info be integrated into EHR PHR best practices
__ purposes of health record are associated directly w/provision of patient care services primary
__ purposes of health record related to environment in which healthcare services are provided secondary
secondary purposes of health record are not related directly to specific __ __ __ patient care encounters
according to Institute of Medicine primary purposes of health record are classified as patient care __, patient care __, patient care __ processes,__ & __ processes, & patient __ delivery; management; support; financial & other administrative; self-management
according to Institute of Medicine primary purposes of health record documents services provided by clinical & allied health professionals working in variety of settings patient care delivery
helps physicians, nurses & other clinical care professionals make informed decisions about diag. & treatments health record documentation
health record is tool for __ among individual patient's different caregivers, ensuring continuity of patient services communication
detailed info stored in health records allows healthcare providers to assess & manage __ risk
health record represents __ __ __ __ by individual patient & represents business record of org. legal evidence of services
refers to all activities related to managing healthcare services provided to patient patient care management
assists providers in analyzing various illnesses, formulating practice guidelines, & evaluating quality of care which is a primary purpose in patient __ __ care management
encompasses activities related to handling of healthcare org. resources, analysis of trends, & communication of info among different clinical departments patient care support services
because health record documents patient's course of illness & treatment, info in it determines __ provider will receive in every type of __ system payment; reimbursement
are trended to assist in managing & reporting costs health record data elements
individuals involved in managing own health & healthcare therefore they are __ __ of health record primary user
education, research, regulation, & policy making are all considered __ __ of health record by Institute of Medicine (IOA) secondary purposes
were added to IOA list of secondary purposes of health record in 2003 public health & homeland security
We had 324 Medicare patients last month. This statement represents information
I am a patient. My medical history incl. info from my physicians & myself is stored on the Internet. This is an example of PHR
Example of a primary purpose of medical record patient care management
Examples of patient care delivery usage of medical record include communication between caregivers
PHR & EHR are synonyms this is false; PHR controlled by patient & EHR controlled by provider
managed care org, integrated healthcare delivery systems, regulatory & accreditation org., licensing bodies, educational org., 3rd-party payers, & research facilities all use info that was originally collected to document patient care
those individuals who enter, verify, correct, analyze, or obtain info from record, either directly/indirectly through an intermediary IOM definition of health record users
__ __ of health records influence clinical care in some way, but they use info from health records for various reasons & in different ways all users
document their services directly in their patients' health records direct patient care providers
submit separate written reports that become part of individual health record other service providers
refers to documentation in health record when questions arise about specific patient's course of treatment or about services patient received patient care manager
patient care __ are also responsible for overall evaluation of services rendered for their particular area of responsibility managers
in order to identify __ & __ patient care managers take details from individual health records & put all info together in one place patterns; trends
on basis of __ __ data, patient care managers recommend changes to patient care processes, equipment, & services combined aggregate
the goal of recommended changes by patient care managers is to __ future outcomes of patient care improve
based on documentation in health record healthcare reimbursement
coded information is used to generate patient __ &/or __ for reimbursement to 3rd-party payer bill; claim
some 3rd-party payers require billers to submit portions of health record along with claims because documentation __ need for services & fact such services were provided substantiates
federal regulation that includes security & privacy provisions; grants most patients right to access their health records; right to amend info in records & add missing info; verify billed services HIPAA
use info based on health records of employee to determine extent & effects of occupational hazards, manage healthcare/disability insurance benefits, & ind. employee's disability claims must be supported by documentation in health record employers
use health record as tool to protect legal interests of facility & its patient care providers attorneys for healthcare organizations
legal reps of physicians & their __ __ __depend of documentation in health records malpractice insurance carriers
attorneys also use info from health record to determine __ __ of individuals mental competency
may also use health record in limited situations, such as investigation of gunshot injuries, child abuse/neglect, domestic violence, & other crimes law enforcement officials
mission is to improve quality of services offered in healthcare facilities healthcare accreditation organizations
every __ healthcare organization subject to periodic accreditation survey participating
__ __ of every accreditation survey is review of facility's health records key component
involve direct review of sample health records from recent & current patients along with review of aggregate statistics related to expected patient outcomes accreditation survey
example of institutional user of health record info accreditation organization
patient care manager & support staff are user that would utilize aggregate data
depends on design of org. systems & processes for collecting original information quality of health record information
to accomplish primary & secondary purposes of health record, data in it must be of __ __ highest quality
__ or __ data could compromise patient care, contribute to incorrect assumptions by policy makers, or result in inaccurate research findings missing; incomplete
one of HIM professionals most important roles is to ensure that health record contains __ __ possible highest-quality data
in 1998 AHIMA developed data quality management model which is based on __ __ four domains
data applications, collection, warehousing, & analysis applying these to accuracy, accessibility, comprehensiveness, consistency, currency, definition, granularity, precision, relevancy, & timeliness data quality management model
data should represent what was __ or __ by original source of data intended; defined
depends on patient's phys. health/emotional state at time data collected, provider's interviewing skills, provider's recording skills, availability of patient's clinical history, depend. of automated equip., & reliability electronic communications media accuracy of data
must have systems in place that identify each patient & support efficient access to info on each patient any organization that maintains health records
authorized users of health record must be able to access info __ when & where they need it easily
every health record system should allow __ __ 24 hrs a day regardless of format in which record is stored record access
previous health records available when/where needed; dictation equip. accessible & working properly; transcription accurate, timely, & readily avail. to providers; comp. data-entry devices working properly & readily avail. to providers affect accessibility of data
access control is relatively straightforward; records stored in locked storage areas accessible to only auth. HIM staff paper-based health record systems
built-in to EHRs; incl. use of passwords, access, cards/tokens, biometric devices, workstation restrictions, & role-based restrictions technology-based access control mechanisms
comprehensiveness means that the record is __ complete
patient ID, consents for treatment, advance directives, problem list, diagnoses, clinical history, diagnostic test results, treatments & outcomes, & conclusions/follow-up requirements must be included in all health records
do not change no matter how many times/in how many ways they are stored, processed, or displayed reliable data
data values are __ when the value of any given data element is same across applications & systems consistent
related data items should also be __ reliable
legitimate __ __ do occur in health records data inconsistencies
numerous references to patient's diagnosis would be __ if they incorporate results of test/findings not avail. at time previous documentation took place legitimate
occurs when different healthcare providers use different terminology for the same things unacceptable inconsistencies
because care/treatment rely on accurate & current data, essential characteristic of __ __ is timeliness of documentation/data entry data quality
every data element should have clear __ & range of __ __ definition; acceptable values
yields accurate data collection precise data definition
in paper-based health records much of documentation/data are collected in narrative format, it is difficult to apply concept of data precision to __ __ narrative text
EHRs provide opportunity to __ data precision improve
reason for collecting a data element must be __ to ensure __ of data collected clear; relevancy
in paper-based health records, __ of narrative detail provided often limits __ of data & info volume; limits
initiatives to improve patient safety & quality of care have spawned development of hundreds of __ __ for which data must be captures in health record during care delivery process measurement criteria
legitimate needs for __ to info must be __ against public's expectation that healthcare providers will respect & protect privacy of patients access; balanced
for health record to fulfill intended purposes, data should be __ enough to meet needs of all record's different users flexible
designed to make data readily avail. & meaningful to those caring for patient standardized forms
when designed appropriately, EHRs can be extremely flexible in way they __ & __ info display; present
EHR has potential to accommodate user needs & enhance confidentiality of __ __ __ patient-identifiable health information
__ & __ are components of health record that will be improved in computer-based systems, EHRs connectivity; efficiency
factor related to efficiency is __ of data structure
data entered into computer-based system for storage from paper-based records is scanned in making the data __ & cannot be used for __ __ unstructured; meaningful comparison
in fully functional EHR systems, structured data captured processes will use controlled __ & __ __ vocabulary; code sets
data collected in __ __ can be analyzed efficiently & compared through computer software applications standard forms
__ __ health records can guide clinicians through process of solving clinical problems properly formatted
3 types of formats commonly used in paper-based record systems are source-oriented, problem-oriented, & integrated
problem-oriented health record format organizes info about problems into database, problem list, initial plans, & progress notes
in 1991 studied various health record formats & could not agree on which format most useful; mere translation of current formats from paper media to computer media would not result in meaningful improvements IOMs Committee on Improving Patient Record
due to disparate record creation & completion processes charac. of hybrid records, org. found same info can be produced from several systems in variety of formats creating need to identify location for __ __ __ for each piece required documentation source of truth
paper-based systems are found to be based on clinician behaviors & record forms that produce substantial waste, imprecision, & complexity
in 2003 IOM added results management, order entry, & order management to EHR functional model
EHR formats for trending & comparing results over time are not available in __ systems paper-based
developed to improve quality of care; provides physicians & other providers ability to place orders via computer from any number of locations & adds decision support capability to enhance patient safety computerized provider order entry (CPOE)
with EHRs both current & previous computerized results can be displayed automatically for care providers to improve effectiveness & efficiency results management
can review structured electronic data & alert practitioners before problems evident, instant access to pharmaceutical formularies, referral databases, & reference literature clinical decision support tools
physician received notification from EHR that patient’s lab had dangerously high value. example of results management
according to AHIMA data quality model, what is term used to describe how data translated into info data analysis
Created by: lfrancois