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HIMTechCh2
Purpose & Function of Health Record
| Question | Answer |
|---|---|
| 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
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