HIT
Quiz yourself by thinking what should be in
each of the black spaces below before clicking
on it to display the answer.
Help!
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| DEEDS | Data Element for Emergency Department Systems
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| HEDIS | Helath Plan Employer Data and Information System
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| MDS | Minimum Data Set
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| MPI | Master Patient Index
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| OASIS | Outcome and Assessment Information Set
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| RAI | Resident Assessment Instrument
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| RHIO | Regional Health Information Organization
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| UCDS | Uniform Clinical Data Set
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| SOAP | Subjective Objective Data Plan
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| Acute care patient record | Usually concerned with one stay/episode
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| Outpatient medical record | Usually limited to one group/clinic
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| Data | Means both computer information and
information in health record. Data refers to
facts
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| Information | Processed data in a useful form that conveys meaning
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| Knowledge | A combination of rules, relationships, ideas and experience
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| Patient Health Record | Primary legal record documenting health
care services provided to a person in any
aspect of the health care system; Repository of information about a single patient
Condition of patient’s health
Care and treatments the patient received
Outcome of car
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| Patient Health Record | Generated by health care professionals as a
direct result of interaction with a patient or with
individuals who have personal knowledge of the
patient
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| Primary Records | Used for patient care; information gathered from patients and their providers, additional information from devices, dx tests
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| Secondary Records | Created after patient care by the analysis,
summarization, or abstraction of
information from primary records; Used for reimbursement or insurance claims, research, government agencies,
quality improvement
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| Demographic Data | Collected upon initial registration, includes name, address, phone numbers, billing info; called face sheet in paper system
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| Physical Exam is also called: | SOAP note (progress notes and physcian's office)
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| Clinical Data | Medical Hx, Physical exam, dx and therapeutic orders/reports, dx images/reports, pre-op and operative reports, referral consultation reports
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| Referral consultation reports must include: | information about the source and reason for the request, evidence that the consultant reviewed the patient’s medical record and examined the patient, documentation of pertinent findings, opinions, and recommendations
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| SOAP Notes | Subjective - Pts description of symptoms and chief complaint; Objective - findings of physical and dx tests; Assessment - Physicians dx; Plan - Physicians orders and plan of care for tx
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| Standard Data Elements | Improves interoperability, defined by NCVHS; Collection of data elements determined to be minimum necessary for particular purpose; Usually represent minimum list of data, elements that must be collected
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| NCVHS | National Committee on Vital Health Statistics
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| RHIO Implementation Issuses | Technical issues related to interfacing with
multiple, unrelated healthcare systems; Economic issues related to who bears cost
of networking, interface programming, and maintenance of translation and MPI
systems, political/ownership issuses
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| Real-time telemedicine | Requires presence of all parties at same time; Challenges: different time zones, state laws
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| Store and forward telemedicine | Allows one party to send information that is
saved, then reviewed; Challenges: delays when additional
information, tests, response needed
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| Teleradiology | transmission of diagnostic images from one
location to another, usually to have images
“read” by radiologist
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| Telemonitoring | Transmission of information from devices that
allow doctors to study multiple measurements
of vital signs or tests in course of patient’s
normal daily activity
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| Advantages of E-visits: | secure msg transmission, creates documented medical records with symptom information, handled by a doctor on call; May be reimbursed as legitimate visit by
Blue Cross/Blue Shield plans and other
private insurance carriers
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