Health Data Concepts
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| centerpiece of the the health care decision making process | patient record
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| data collected/combined from many different sources | aggregate data
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| aggregate data contains essential data/info to answer key questions of patient care, related to the | who, what, when, where, why, and how
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| used for participation, monitoring care, document services received, proof of identity/ disability & verified billed services | medical data
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| support or promotion of something | advocacy
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| taken an advocacy position in promoting understanding of PHR through MyPHR consumer ed courses & website | AHIMA
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| individual licensed/certified to deliver care to patients | practitioner
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| physicians, nurses, & other clinicians treating a patient, use records as primary means of | communication
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| practitioner(s) at follow-up facility/agency use record for | continuing care
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| nursing staff in residential facility use data for | care plans outlining nursing interventions
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| health record collects that data that documents | provisions of service
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| use data to evaluate care, monitor use of resources, & receive payment for services rendered | providers
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| analyze financial & case mic data for business planning & marketing activities | administrators
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| are the basis of claims processing to pay for health care services provided | data
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| include private insurance co., MCOs, & fiscal intermediaries (FIs) who process claims for Medicare & Medicaid | third-party payers
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| are currently the basis for reporting & managing costs of care | billing data
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| organizational resources including supplies, equipment, services, & providers can be taken into consideration in | utilization review
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| case management facets of admission, continued stay, & discharge from an inpatient facility & day-to-day management of specific chronic problems have existing | criteria
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| use data as basis for analysis, study, & evaluation of quality of care given to the patient | quality assessments & improvement committees
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| uses secondary health care data to ensure that only qualified physicians practice medicine | National Physician Data Bank
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| recent studies by IOM have increased focus on | patient safety
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| review patient records to provide public assurance that quality health care is being provided | accrediting, licensing, & certifying agencies
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| data serves as evidence in assessing compliance with | standards of care
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| data serves as evidence in accrediting various | HCOs
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| reviews of governmental financial resources are done on a | continuing & retrospective basis
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| public health is concerned with threats to overall health of a community on the basis of | population-based health care data analysis
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| focuses on treatment of individual | medical health care
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| public health departments & programs, established by all levels of government, which include | surveillance/control of infectious diseases, prevention/vaccination programs, & promote health behaviors
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| used to evaluate & assess job-related conditions/injuries & determine occupational hazards in workplace | health care data
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| health data is used by employers to | select HCOs, evaluate quality & manage costs
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| use as documentary evidence of patient's course of treatment to protect legal interests of all parties involved in patient health care | attorneys & courts in judicial process
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| data may aid in determining the for admission of ___ ___ for treatment | mentally ill
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| use info related to vital statistics, disease incidence & prevalence, report of child/elder abuse, etc. to provide aggregate data for | public policy development
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| data is used by HCOs to support need for | continuing & addition of services
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| assists educators/trainers in tying theory learned to practical aspects of care | data documentation
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| significant aspect of improvement of care & assessment of effectiveness of treatment & improved methods for future care | clinical research
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| help with early disease detection | epidemiologists
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| report data that public needs to know, i.e. health hazards, diseases affecting public health & new developments in medical research | media reporters
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| used in everyday care setting, data in PRs are essential resource for | clinical & administrative decisions
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| effective decision making proceeds through the following steps: | identify problem, data collection, develop alternatives, select best alternative, action, follow-up evaluation
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| data collection has significant impact on ___ & ___ of decision-making process | efficiency & effectiveness
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| ___ & ___ data enhance likelihood of effective decision, but do not guarantee it | well-defined & accurately collected
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| must carefully consider purpose for data collection while gathering sufficient data items, but no more than required | HIM Professional
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| staff time for entry/review, management & computer time/storage associated with data collection are a | significant cost
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| satisfy an identified need for retention, retrieval, & use of data to generate meaningful information | only reason to collect data
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| aid in facilitating data exchange & reducing misunderstandings | definitions of data elements
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| word is plural & used whenever more than one element is described | data
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| describes a single data element | datum
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| data processed into meaningful form; adding to representation, telling recipient something not known before | information
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| collects data & generates a report, either on paper or electronically; "repository of information" | patient health record
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| health record is a more comprehensive term that includes | prevention & screening data
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| more typically refers to encounters related to illness | medical record
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| record that is used by practitioners while providing care services to review patient data or document own actions, observations, or instructions | primary patient record
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| subset derived from primary patient record contains selected data elements, helping clinician/nonclinician in supporting evaluating & advancing patient care | secondary patient record
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| refers to administration, regulation & payment functions | patient care support
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| refers to quality assurance, utilization review & medical/legal audits | patient care evaluation
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| refers to research | patient care advancement
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| comprehensive patient record complied & accessible over patient's life span, from birth to death | longitudinal patient record
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| has lead the way in creating longitudinal electronic patient records to serve their patient population | VA
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| a combination of discrete data elements & narrative in various media | current patient health record
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| collection, analysis, & dissemination of health-related info are crucial aspects, in addition to national leadership of health data standards & information privacy policy | DHHS
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| coordinates all health/nonhealth data collection & analysis activities of the department | DHHS Data Council
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| statutory public advisory body to DHHS on health data, statistics, & national health info policy | National Committee on Vital & Health Statistics (NCVHS)
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| NCVHS also advises DHHS on | HIPPA implementation
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| part of CDC of the DHHS and is federal government's principal vital health & statistics agency | National Center for Health Statistics (NCHS)
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| data provided by NCHS are used by | policy makers, Congress, administration, medical researcher
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| NVCHS leading government agency in standardization of health info, through | uniform data sets
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| group of data items/elements & their definitions; often defined values for each data element | data set
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| data set that has defined values for each element is useful for | systematic data collection & measurement
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| formally made public, most frequently used in relationship to act of formally, publicly declaring new statutory/administrative law when it received final approval | promulgated
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| data sets promulgated by NCVHS have influenced claim forms on which Medicare/Medicaid data sets are based and | Conditions of Participation
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| uniform specification for data encountered into hospital ED records. | DEEDS - Data Elements for Emergency Department Systems
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| comprehensive functional assessment of long-term care patients | MDS - Minimum Data Set for Long-Term Care
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| core items of comprehensive assessment for adult home care patients; forms basis for measuring patient outcomes | OASIS - Outcome and Assessment Information Set
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| improve ability to compare data in ambulatory care settings | UACDS - Uniform Ambulatory Care Data Set
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| uniform collection of data on in patients; used by federal/state agencies | UHDDS - Uniform Hospital Discharge Data Set
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| intended to describe minimal data about patients, resident, or clients | DEEDS, MDS, OASIS, UACDS, UHDDS
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| currently hampered by inability to link data sets from various sources | performance monitoring & outcomes
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| vitally important in managed care field, in order to follow patients through continuum of care and at multiple sites | standardized data elements
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| info may not have to be collected at each encounter | first 12 core health data elements
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| the only (1) of the first 12 core health data elements, which would need to be collected at each encounter | unique identifier #1
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| CDC initiative that promotes use of data & info standards to advance development of efficient, integrated, & interoperable public health surveillance systems at state, local & federal levels | Electronic Disease Surveillance System NEDSS
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| continuing, automatic capture & analysis of data that are already available electronically | primary goal of NEDSS
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| reduce review by state/federal gov. & may facilitate payment for services, assuring consumers/payers of high quality of care | reasons for accreditation
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| source for info about quality of nation's MCOs | National Committee for Quality Assurance NCQA
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| to measure performance the NCQA uses | Health Plan Employer Data & Information Set HEDIS
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| "Practice Briefs" are AHIMA's | professional practice guidelines
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| present best practices & excellent for personal continuing education & evaluation of present organizational practices | "Practice Briefs"
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| focuses of optimal use of health care IT & management systems for the betterment of human health | Healthcare Information and Management Systems Society HIMSS
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| provides leadership in developments & implementation of information systems to improve patient care | American Medical Informatics Association AMIA
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| research-based management data set that includes 17 across-settings elements | Nursing Management Minimum Data Set NMMDS
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| understanding rules, standards & regulations is a solid foundation for | developing a high quality health record
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| essential to consider specialized needs of all | users of the record
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| ensures computer views/screens & paper forms are designed to facilitate collection of data elements as care is provided | understanding flow of data & information
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| responsibility to identify who may provide care & then document that care in patient record | health care organization
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| "any individual permitted by law & by the organization to provide care, treatment, & services without direction or supervision" | licensed independent practitioner (LIP)
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| all forms and views, including all sides & segments of multipart paper forms & all screens of computer views must identify | the patient
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| assigned to link patient to their record(s); used on all record forms/views to collect all patient data in correct record to be accessed by computer database query | unique identifier number
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| the patient name and number are contained in a database called | the master patient index (MPI)
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| index that identifies all patients who have been treated by facility & lists the number associated with the name | master patient index (MPI)
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| master patient index (MPI) can be maintained manual,y or as part of a | computerized system
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| data collect before care rendered to include sufficient info to identify patient positively along with basic patient clinical data | registration record
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| registration record is one of the most commonly | computerized forms
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| personal data elements, sufficient to identify patient, collected from patient/patient's rep & not related to health status or services provided | demographics
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| identification sheet, face sheet, or admission-discharge record, are all names associated with | the registration record
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| body of form contains statement indicating patient agrees to receive basic, routine services, diagnostic procedures & medical care; in addition to statement explaining outcomes cannot be guaranteed | consent to treatment
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| covered entities are required to provide patients with a Notice of Privacy Practices & update as needed; good faith effort to get written acknowledgment of receipt | Acknowledgment of HIPPA Notice
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| patient's signature authorizes exchange of personally identifiable health info between provider & other organizations | consent to release information
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| form lists patient's rights when under care | acknowledgment of patient rights
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| give instructions regarding patient's/guardian's wishes in special medical situations | advance directives
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| effective Dec. '91 requires all patients older than 18 be given written info about their rights under state laws so they can make decisions concerning medical care, including right to refuse care | Patient Self-Determination Act (PSDA)
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| special consent required to authorize any nonroutine diagnostic/therapeutic procedures before performed on patient | consent to special procedures
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| consent to special procedures must include physician's explanation in lay terms to procedure named, risks of having/refusing procedure, avail alternative procedures & likely outcome in order for | it to be valid
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| inventory of property & valuables brought by patient should admission be required | property & valuables list
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| state laws require filing of vital records including | birth and death certificates
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| Joint Commission requires a report of comprehensive H&P be completed & available within | 24 hours, or sooner if surgery is to be performed
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| Joint Commission permits an interval history & phys exam when patient is admitted within | 30 days for same reason
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| this key document is usually dictated and transcribed | patient H&P
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| forms foundation for establishing provisional diagnosis and developing treatment plan | medical history and review of systems
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| consist of chief complaint/description of symptoms, history current illness, medical history, family history, & social history including health maintenance & review of systems | components of medical history
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| when a patient is a child/adolescent the Joint Commission requires including a | developmental age evaluation & educational needs assessment
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| positive data on H&P | all symptoms documentation
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| negative data on H&P = | normal
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| adds objective data | physical examination
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| subjective data | patient history
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| if several diagnoses fit patient's clinical presentation, the list of alternatives is called | differential diagnosis
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| interdisciplinary patient care plan is not required for | physician's offices/clinic & acute-care hospitals
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| foundation around which patient care is organized because it contains input from unique perspective of each discipline involved | interdisciplinary patient care plan
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| because of its central role in planning/providing care, the care plan is valuable for evaluating individual patient care and | overall organizational patient care performance
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| are needed for any type of treatment/diagnostic procedure | physician's orders
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| set of routine orders used for patients with particular diagnosis/prepare for/follow up a procedure | standing orders
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| it is particularly important that all orders are dated and signed by LIP giving the order because | they initiate action
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| Joint Commission requires that verbal/telephone orders for exchange of critical test results be verified through | "read back" procedure
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| admission order is written at | initiation of care
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| should be written for every patient once the physician determined release is appropriate | discharge orders
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| lack of discharge order, in patient record, may indicate patient left | against medical advice (AMA)
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| interval systems that document patient's illness & response to treatment as specifically as possible | progress notes
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| contains an opinion about patient's condition by practitioner other than attending physician | consultation report
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| require that medical staff bylaws, rules & regulations address status of consultations | Conditions of Participation for hospitals
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| concisely reviews patient's course; should be written/dictated immediately after discharge or authenticated | discharge/interval summary
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| procedures that require more than local anesthetic also require | anesthesia report
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| describes planned procedure, choice of anesthetic, and exam of patient | preanesthesia note
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| documents patient's condition, specifying nature & extent of any complications; should be completed within 24 hrs after surgery | post anesthesia report
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| requires at least (1) postanesthesia visit that describes presence/absence of anesthesia-related complications | Joint Commission
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| requires that recovery room report include patient's condition & level of consciousness when entering/leaving the unit | the Joint Commission
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| all patient records, for patient's who undergo surgery must have an | operative report
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| documents tissue exams that may be microscopic in addition to macroscopic | pathology report
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| should be records in patient's record within 3days of autopsy | provisional autopsy diagnosis
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| American College of Obstetricians & Gynecologists, identifies recommended content for obstetrical data in its | Standards for Obstetric-Gynecological Services
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| begins in office or clinic of OB or nurse midwife & should be made available for access to hospital by 36 week of pregnancy | antepartum record
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| tracks patient from admission through delivery to postpartum period | labor & delivery record
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| includes information about condition of mother after delivery, with attention to assessing lochia & condition of breasts, fundus & perineum and postoperative status | postpartum record
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| include regular history, physical exam, & progress noted, with addition of special identification data | neonatal record
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| includes history regarding pregnancy, any diseases, delivery, Apgar score, any prematurities/abnormalities, & any problems occur before transfer to nursery | birth history
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| while neonate is still in delivery room, 2 identical bands prepared noting mother's # & neonate's sex & time of birth, one band placed on mother & one on child; band # and ID form about mother & neonate also prepared | neonatal identification
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| responsible for identification process & signs sheets along with any participating OB | delivery room nurse
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| repeats birth & concentrates of detailed description of neonate's appearance | neonatal physical exam
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| Joint Commission requires that neonates who receive oxygen therapy should have the concentration recorded at | intervals according to policies/procedures of facility
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| regardless of the form, these notes describe patient & condition in objective, behavioral terms; includes interventions & patient's response as well as admission/discharge notes | nursing notes
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| used to plot the patient's vital signs; usually includes 6 entries/day , nurses typically sign form once then initial thereafter | graphic sheet
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| provides detailed record of medicines given orally, topically, or by injection, inhalation, & infusion; date, time, dose & route of administration included; practitioner giving dose signs sheet | medication sheet
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| typically collected by practitioners other than physicians & nurses, w/exception of patient/family teaching and case & staff conferences where variety of clinicians participate | ancillary data
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| records electrical activity of heart; | electrocardiograph
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| shows 5 waves, P indicating contraction of atria, followed by Q,R,S & T consecutively which relate to contraction of ventricles | normal electrocardiograph recording
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| graphic tracing produced by plotting the waves, against time on a continuous paper roll/computer view | electrocardiogram
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| contains cardiologist's signed interpretation & may include tracing | electrocardiographic record
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| when tracings are not provided, in the electrocardiographic record, they are stored in | the laboratory for reference
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| detail analysis/exam of blood, urine, stool & other body substances; results provided by lab; should be completed/reported promptly; may be on standard paper/small slips designed for taping on mounting sheets | laboratory reports
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| laboratory results can be profiled over time & presented in graphic format, when in an | electronic view
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| American Association of Blood Banks has particular requirements, when blood baking is done, detailed in its | Technical Manual
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| describe diagnostic/therapeutic services; procedures include modalities which create visual image; physician, usually a radiologist, dictates or writes description of image their impression | radiology & imaging reports
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| the image can be viewed on-line & portion can be enlarged in a | computerized view
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| films & computer images are stored in | departments that produce them
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| closely resemble consultation process; major procedures requiring special consent; treatment plan written, each treatment reported incl. amount radiation given/dose & summary | radiation therapy
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| radiation therapy reports are signed by | therapeutic radiologists
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| include assessments & treatment plans designed to restore patient function; therapist documents services, incl. patient response & signs report/progress notes | therapeutic services
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| therapeutic services notes are __ & __ oriented | objective & goal
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| Joint Commission has documentation requirements for each of the therapeutic services, particularly as they relate to | rehabilitative care
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| contain data on patient's background, social info, & problems identified by patient, family, & case mgr.; formal record includes plan of action, progress notes, & discharge note | case management & social service record
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| has access to great deal of sensitive personal info in addition to private medical info | case manager
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| wide variety of practitioners engage in __ & __ __ along the continuum of care | patient & family teaching
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| regardless of profession/setting teaching & redemonstration of understanding should be described in detail; | patient & family teaching & participation
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| patient & family teaching & participation, preprinted materials should be noted & kept on file in | the HIM dept
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| family participation in planning, goal setting, & carrying out of lifestyle changes, therapies or other services may be required documentation by | some segments of health care
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| begun at time of admission/initiation of services; gives general assessment of plans to maintain continuity after this episode of care | discharge & follow-up plan
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| efforts that support communication, continuity of care, & overall high-quality patient care | documentation guidelines
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| if health record is to fulfill unique roles for patient, providers, as legal record, for researchers, & education, content must be | of high quality
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| must only document their own interactions, avoiding charting for others; legally responsible for their care & entries | authors
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| help remind practitioners of care elements & essential documentation | forms & views
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| should never be written in anticipation of care being provided because other events may intervene, creating errors in sequence of events | notes
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| are best understood when they are specific & exact, including use of standard terms spelled correctly | descriptions
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| notes do not require | complete sentences
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| not a routinely require word, in chart notes, because it is understood | "patient"
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| save substantial time for practitioners, but pose significant risk of being misunderstood through poor handwriting or duplicate meanings | abbreviations, acronyms, & symbols
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| official list of approved abbreviations maintained by HCOs, to avoid misunderstandings from poor handwriting or duplicate meanings | official abbreviations list
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| Joint Commission established national patient safety goals, prohibiting use of | "dangerous" abbreviations, acronyms, & symbols in patient record
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| historic charting problems, such as legibility & author identification, are substantially resolved by the use of | EHRs
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| promotes good quality photocopying, faxing, & document imaging for paper-based records | use of blank ink
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| for paper-based records no __ __ should remain between entries | blank lines
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| when errors occur, on paper-based records, corrections should be made with a __ __, so as not to obscure the entry | single line
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| when errors occur, on paper-based records, corrections should be initialed and noted with | "mistaken entry" or " error"
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| identifies an author of an entry in patient record & that entry has been verified/validated by the author | authentication
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| prior to authentication __ or __ should be made to an entry | additions or corrections
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| Joint Commission requires that the minimum of four documents be authenticated, including | H&Ps, operative rpts, consultations, & discharge summaries
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| initials may be used, for authentication, when there is a __ available in record providing full signature & related initials | legend
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| because of their high potential for abuse __ __ should be discouraged, for authentication | signature stamps
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| e-mail signature, digitized image of signature, unique logon & PIN, unique biometric identifier, or digital signature using encryption are examples of | electronic signatures
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| organization of paper-based health record is referred to as its | format
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| reference that determines facility's standard sequence of pages to be followed in each record is called | chart order
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| should approve forms to be used in clinical record as well as organizing format | organization's info management or medical record committee
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| most common paper-based health record format; record is organized into sections according to practitioners who are the source of both treatment & data collection | source-oriented medical record
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| in source-oriented medical record, within each section, sheets are arranged in ___ ___ | chronological order
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| source-oriented medical record, during admissions current episode is typically kept at nursing unit in | reverse chronological order
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| is record is kept in same order during & after care it may also be referred to as | "universal" order chart
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| advantage of standardized source-oriented records is speed with which | an individual sheet can be located
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| lack of clear picture of patient's problems & how each dept is contributing to their resolution is | disadvantage of standardized source-oriented records
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| developed by Dr. Lawrence Weed in 1960s in response to major deficiency in source-oriented record format | problem-oriented medical record (POMR)
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| system focuses on documentation of logical, organized plan of clinical thought by practitioners | POMR
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| four part of the POMR | database, problem list, initial plan & progress notes
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| the database of the POMR was | early minimum data set (MDS)
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| dynamic document showing titles, numbers & dates of problems & serves as table of contents for the record | POMR problem list
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| stated at the level of physician's current understanding & modified as further data accumulates; may include initial symptoms/well-defined diagnoses; past/present, financial, demographic & medical | POMR problem
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| described what will be done to investigate/treat each problem; refer to problem number | POMR initial plans
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| need to collect more decision-making info, therapy & patient education are the three types of | POMR problem numbers
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| written in a distinctive style according to acronym SOAP & numbered to correspond to the problems | POMR progress notes
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|
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| considered a special progress note in the POMR | discharge summary
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|
||||
| creates holistic picture of patient & their care providing excellent communication & evaluation tool highlighting thinking process are all | advantages of POMR
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| time &, commitment needed on part of practitioners to implement & maintain system are | disadvantages of POMR
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|
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| the full system of the POMR has not been widely accepted for use with paper-based health records, with exception to | SOAP style progress notes & problems list
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| problem list & SOAP notes, are components of POMR used in | ambulatory settings
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| list of goals & objective, serving same function as problem list were transformed for use by | behavioral health
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| behavioral health may use modification of SOAP notes that combines "S' & "O" into | "Data"
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| data, assessment, and plan used to structure progress notes | DAP
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| strictly chronological without any divisions by source, keeps episode of care clearly defined by date | integrated medical record
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| keeping episode of care clearly defined by date, is an advantage of integrated records when the __ __ __ is considered | flow of care
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| info from same source is not easily compared, is | disadvantage of integrated medical records
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| resemble team approach of POMR, providing more holistic view of patient | progress notes of integrated medical records
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| particular way of looking at data in a database; organizes data visibly in way that meets needs of user; permit recording of varying data w/out recopying constant info | view
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| different views do not affect the physical ___ of the database | organization
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|
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| when well designed & controlled they enhance tech by providing smooth link in communication process | forms, views & templates
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| should emphasize the needs of the user | form or view design
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| plays leadership role by providing knowledge of rules & regulations related to health record content, medical science, computer applications, flow of data, & info needs of health care delivery system | HIM Professionals
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|
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| collecting enough of the right type of data to satisfy the range of users means clearly defining the purpose of | the form or view
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| identify patients & practitioners & instruct them step by step in what data items to gather, where to obtain them & how to record them | forms
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|
||||
| facilitate complete and accurate documentation is the foundation of | effective decision making
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|
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| all elements of history, review of systems, and physical exam are collected when | standardized
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|
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| the history & physical form or view ___ majority of communication between patient & practitioner, and others as the need arises | structures
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|
||||
| effective & efficient sequencing of form/view should follow | from left to right and top to bottom
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|
||||
| makes referencing to both items & written instructions on completion of forms easier and faster | numbering items
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|
||||
| when standard definitions are not available the form/view should | provide the definition
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|
||||
| standard definitions are particularly important when | linked databases are used
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|
||||
| aspect of form/view design, which promotes consistency, is development of | master format/template
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|
||||
| should briefly identify who should complete data items & provide any additional guidance necessary | instructions
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|
||||
| reference to the location of instructions should be made on | the face of the form
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|
||||
| provides considerable savings in time, effort & materials | simplification
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|
||||
| necessary to standardize assembly of sequence of various document within paper health record, also called chart order | a guide
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|
||||
| title & subtitle identifying the form are typically positioned in | the header
🗑
|
||||
| the title & subtitle, identifying the form, should appear at the bottom when the facility | binds records at the top
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|
||||
| on each form the form titles should appear in the same | font & font size
🗑
|
||||
| contains info about the form, such as control number, edition date & page number/letters, usually at the left | the footer
🗑
|
||||
| operative report should be dictated/written ___ after surgery, signed & put in the records ___ | immediately; ASAP
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|
||||
| on paper forms, there should be a place to imprint the patient's __ & __ on all pages of a multipage form/on each side of double-sided form | name & health record number
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|
||||
| should explain purpose of the form; usually title sufficient, occasionally subtitled needed to understand form to complete appropriately | Introduction & Instructions on paper forms
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|
||||
| contains main content of paper form | body
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|
||||
| on paper forms, provides space for authenticating or approving signatures | close
🗑
|
||||
| NCR | no-carbon required
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|
||||
| when creating a paper form, the creator must take into consideration the spacing in order to | compensate for 1/3" vertical height, for handwritten words
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|
||||
| when creating a paper form, __ should be well chosen and contribute to readability | type styles, or font(s)
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|
||||
| vertical/horizontal lines that structure a paper form; serve to divide form into logical sections, & direct data entry length & location | rules
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|
||||
| for paper form(s), if several people have areas to complete, data sets each party is to present should be presented in | the order of completion
🗑
|
||||
| desirable on paper form(s) for long sections that are handwritten | horizontal lines
🗑
|
||||
| should be located in upper left of the boxes in small font sizes | box titles or captions
🗑
|
||||
| sometimes called ballot boxes; when used there should be consistency throughout form, whether located on immediate left/right of the caption | check boxes or line
🗑
|
||||
| vertical/horizontal line rules, check boxes or lines should be aligned ___ when appropriate | vertically
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|
||||
| rules that frame a section; preferable to screening/shading; can create a margin around an entire form | borders
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|
||||
| provide visual appeal & important for printing; allowances should be made for punched holes & printing equipment | margins
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|
||||
| forms to be types should have, at least, ___ ___ at bottom to avoid paper slippage in platen when typing near bottom of the page | 1/2" margin
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|
||||
| if data is to be entered on computer screen/view & then printed on preprinted paper forms, refer to ___ or ___ ___ for correct data placement | vendor or machine specifications
🗑
|
||||
| original from which copies of paper form(s) are made; may be designed internally; when elaborate/formal printing needed should be created by professional typesetter | masters
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|
||||
| refers to a paper form(s) size and special properties | physical building
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|
||||
| require planning to provide sufficient copies & construction; packet creates precollated & prefastened w/ perforated stub; advantages - standardization | multipart paper form(s)
🗑
|
||||
| disadvantages: limited # of copies, carbon must be removed, ink smears, NCR difficult to read beyond 1st 2-3 pg, ink can fade over time, & photocopying impossible to read | paper multipart form(s)
🗑
|
||||
| may be produced as individual form sets or continuous-feed strips | paper-based form(s)
🗑
|
||||
| paper-based form(s) prepared as unit sets consisting of single forms glued together along one edge, which create | a pad of paper-based form(s)
🗑
|
||||
| reflects how easy the paper is to read & write on | suitability
🗑
|
||||
| concerns how well paper-based form(s) stands up to handling | durability
🗑
|
||||
| reflects how long paper-based form(s) lasts in hard copy | permanence
🗑
|
||||
| extremely important to be suitable for use w/copiers, fax, & scanning equipment; 20-24lbs recommended for health records | paper weight
🗑
|
||||
| ink type best suits reproduction & should meet scanning specifications | black ink
🗑
|
||||
| use of ___ ___ ___ should be limited because it adds to the cost of the form | additional text colors
🗑
|
||||
| include in-house preparation & commercial printing | duplicating
🗑
|
||||
| entails the creation of master & reproduction, usually by photocopy; more expense; used for trial period/when only small amount of forms needed | include in-house preparation
🗑
|
||||
| process in which a lithographic stone or metal or paper plate is used to make an inked impression on a rubber blanket that transfers it to the paper being printed, instead of being made directly on the paper | offset printing, offset lithography
🗑
|
||||
| more cost effective, the in-house master can be used for | offset printing
🗑
|
||||
| best for providing added features (i.e. hole punching, perforation, collating, etc.) in conjunction w/printing process | commercial printers
🗑
|
||||
| provide definitions for data elements that comprise a data set; should provide agreed-to definitions for each data element in data set & include additional information needed to properly construct data set | data dictionaries
🗑
|
||||
| grouping of data elements into data element groups; includes logical groupings of data elements; sometimes given names & defined in data dictionary in a manner similar to less complex data elements | element group
🗑
|
||||
| specification of the allowable values for each data element; allowable values expressed as enumerated list of values, reference to enumerated list of values, or predicate expression describing allowable values | element domain
🗑
|
||||
| specification of allowable values may include constraints based upon the value of | one or more other data elements in the data set
🗑
|
||||
| specification of conditional presence for each data element | element default
🗑
|
||||
| may be specified for optional data elements; specification of what the recipient of the data set can assume to be the value for data elements not sent in the data set | default value
🗑
|
||||
| specification of the derivation algorithm for derivable data elements | element derivation
🗑
|
||||
| may be as simple as counts, sums, differences, and averages, or may involve complex rules and procedures | derivable data elements
🗑
|
||||
| Data sets containing derivable data elements will sometimes also include the raw data needed to perform | derivation for audit or data validation purposes
🗑
|
||||
| involves collecting data definitions currently in use, assessing the disparity in data definitions, and reconciling the discrepancies | data dictionary project
🗑
|
||||
| generally contains technical, business, & clinical definitions for data & includes instructions for mapping technical definition in a computer system to agreed-to business/clinical definition for use in info collection, analysis, & dissemination | resulting data dictionary
🗑
|
||||
| developing a data dictionary is a critical step in the implementation of | computerized patient record system or clinical data warehouse
🗑
|
||||
| regulatory & accrediting bodies such as the Health Care Financing Administration & the Joint Commission on Accreditation of Healthcare Organizations also produce data dictionaries as part of | data set specifications
🗑
|
||||
| defined collection of data elements for a particular business or clinical purpose | data set
🗑
|
||||
| software developers, regulators, accrediting agencies, government agencies, researchers, payer organizations, provider organizations, & standards bodies have all defined | data sets in healthcare
🗑
|
||||
| level of abstraction in a data set can range from | very specific to somewhat conceptual
🗑
|
||||
| more complex the data set, the more important it is that the parties who will be using it agree on | data set definitions & rules for data set's construction
🗑
|
||||
| data dictionary must accompany | the data set
🗑
|
||||
| because data elements are reused across data sets, it is ideal if elements in different data sets can be drawn from | a common data dictionary
🗑
|
||||
| dictionary needs to be organized in a way that makes it relatively easy to find desired data __ & to detect unintended data __ | element; redundancies
🗑
|
||||
| data models have become a popular and effective means of meeting the requirements of | reusable data dictionary
🗑
|
||||
| provide a contextual framework & graphical representation that aid in definition of data elements; data elements are organized into classes, & each class represents some object in healthcare | data models
🗑
|
||||
| can be a concept, person, place, thing, or event | an object in a data model
🗑
|
||||
| contains a description of the class of objects it represents; set of properties that include the attributes & associations to no other in the model | class in a data model
🗑
|
||||
| some fact of interest about the class that could be carried in a data element of a data set | attribute
🗑
|
||||
| two popular and widely used standards for data modeling; provide a formal language for expressing and defining classes of concepts and their properties | IDEF6 and UML7
🗑
|
||||
| are an effective means of capturing useful, normalized groupings of data elements | classes w/in a data model
🗑
|
||||
| capturing element conditionality, defaults, and derivation specification in the data model is best delayed until | using data model to define data sets
🗑
|
||||
| should be added to the data model's data dictionary as an extension of the model | specifications in data model
🗑
|
||||
| significant advantage of keeping derived data elements out of the base data model and out of the graphical expression is | reduction of redundant data definitions
🗑
|
||||
| contains non-derived, unique, atomic data elements | core data dictionary
🗑
|
||||
| contains derived, qualified, & composite data elements | extension to core data dictionary
🗑
|
||||
| require data elements to convey concepts that are unique w/i scope of model & not encapsulation of significant subordinate concepts | rules of data modeling
🗑
|
||||
| rules of data modeling are known as | normalization
🗑
|
||||
| normalization enables construction of data model that is resilient, extensible, & applicable to | multiple users
🗑
|
||||
| data elements included in the extended data dictionary are not constrained by | rules of normalization
🗑
|
||||
| used in data sets are defined in the extended data dictionary, along with their rules for derivation | derived data elements
🗑
|
||||
| may also be defined in extended dictionary as equivalent to data elements in core data dictionary | alias names for data elements
🗑
|
||||
| description should include text that explains when it is to be used | alias
🗑
|
||||
| convey concepts that are a subset of a concept in the core data dictionary | qualified data elements
🗑
|
||||
| contains qualifier word preceding name of a core data element | name of qualified data element
🗑
|
||||
| declares the subset | qualifier word
🗑
|
||||
| extended data dictionary might also include data elements that are ___ of data elements included in core data dictionary | composites
🗑
|
||||
| contents of the extended data dictionary are best defined during the process of | building a specification for a data set
🗑
|
||||
| data sets derived from a data model will have their entire contents drawn from the | data model data dictionaries
🗑
|
||||
| new data element is added to the core data dictionary, it must also be added to the | data model's graphical representation
🗑
|
||||
| more the data model is used as the source of data elements for data sets, the more complete it becomes and the more useful it is as a tool for | ensuring consistency among multiple data set
🗑
|
||||
| complement each other & , when used together, enhance their effectiveness in creating well-defined, semantically rich, reusable data elements | features & advantages of data dictionaries, data sets, & data models
🗑
|
||||
| is an example of data model-driven approach to constructing data dictionaries and data sets, to achieve consistency in data element and data set definitions | HL7 version 3 message development methodology
🗑
|
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