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