Purpose & Function of Health Record
Quiz yourself by thinking what should be in
each of the black spaces below before clicking
on it to display the answer.
Help!
|
|
||||
|---|---|---|---|---|---|
| professional org. that establishes standards against which healthcare org. are measured & conducts periodic assessments of performance of individual healthcare org. | show 🗑
|
||||
| data extracted from individual health records & combined to form deidentified info about groups of patients that can be compared & analyzed | show 🗑
|
||||
| credentialed healthcare workers who is not physician, nurse, psychologist, or pharmacist | show 🗑
|
||||
| division of DHHS responsible for developing healthcare policy in US & administering Medicare program & federal portion of Medicaid program | show 🗑
|
||||
| show | coding specialist
🗑
|
||||
| legal/ethical concept establishes healthcare provider's responsibility for protecting health records & other personal/private info from unauthorized use/disclosure | show 🗑
|
||||
| dates, numbers, images, symbols, letters & words that represent basic facts and observations about people, processes, measurements, & conditions | show 🗑
|
||||
| show | data accessibility
🗑
|
||||
| show | data accuracy
🗑
|
||||
| extent to which healthcare data are complete | show 🗑
|
||||
| show | data consistency
🗑
|
||||
| extent to which data are up-to-date | show 🗑
|
||||
| show | data definition
🗑
|
||||
| level of detail at which attributes & values of healthcare data are described | show 🗑
|
||||
| show | data precision
🗑
|
||||
| managerial process ensuring integrity of org. data during data collection, application, warehousing & analysis | show 🗑
|
||||
| extent to which healthcare-related data are useful for purpose for they were collected | show 🗑
|
||||
| show | data timeliness
🗑
|
||||
| show | diagnostic codes
🗑
|
||||
| show | electronic health record (EHR)
🗑
|
||||
| show | health record
🗑
|
||||
| health record that includes both paper & electronic elements | show 🗑
|
||||
| factual data that have been collected, combined, analyzed, interpreted, &/or converted into form that can be used for specific purpose | show 🗑
|
||||
| system of health record org. in which all paper forms are arranged in strict chronological order & mixed w/forms created by different departments | show 🗑
|
||||
| show | personal health record (PHR)
🗑
|
||||
| show | problem-oriented health record format
🗑
|
||||
| show | procedural codes
🗑
|
||||
| show | quality improvement organization (QIO)
🗑
|
||||
| show | reimbursement
🗑
|
||||
| means to control access & protect info from accidental/intentional disclosure to unauthorized persons & forms of unauthorized alteration, destruction, or loss | show 🗑
|
||||
| system of health record org. in which info arranged according to patient care dept. that provided care | show 🗑
|
||||
| show | 3rd-party payers
🗑
|
||||
| show | transcriptionist
🗑
|
||||
| show | utilization management organization 1
🗑
|
||||
| show | examples of allied health professionals
🗑
|
||||
| show | Health Care Financing Administration (HCFA)
🗑
|
||||
| data __ & __ are interchangeable | show 🗑
|
||||
| depending on the setting a health record can also be called | show 🗑
|
||||
| until 2002 quality improvement organization (QIO) was called | show 🗑
|
||||
| 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 | show 🗑
|
||||
| show | utilization management organization 2
🗑
|
||||
| show | principle repository
🗑
|
||||
| modern __ __ for health record did not begin until early 20th-century | show 🗑
|
||||
| show | patient records
🗑
|
||||
| show | medical record
🗑
|
||||
| show | resident records
🗑
|
||||
| show | client record
🗑
|
||||
| show | charts
🗑
|
||||
| show | document; report
🗑
|
||||
| data represents __ & information represents __ | show 🗑
|
||||
| show | health information management (HIM) professionals
🗑
|
||||
| show | electronic; interactive
🗑
|
||||
| show | paper-based; computerized
🗑
|
||||
| is computerized, contains complete health history of individual, & is accessible online to anyone that have been given access by individual | show 🗑
|
||||
| currently there is no __ __ for individual to maintain PHR | show 🗑
|
||||
| recommended that PHR info be integrated into EHR | show 🗑
|
||||
| __ purposes of health record are associated directly w/provision of patient care services | show 🗑
|
||||
| __ purposes of health record related to environment in which healthcare services are provided | show 🗑
|
||||
| show | patient care encounters
🗑
|
||||
| show | delivery; management; support; financial & other administrative; self-management
🗑
|
||||
| according to Institute of Medicine primary purposes of health record documents services provided by clinical & allied health professionals working in variety of settings | show 🗑
|
||||
| helps physicians, nurses & other clinical care professionals make informed decisions about diag. & treatments | show 🗑
|
||||
| show | communication
🗑
|
||||
| show | risk
🗑
|
||||
| health record represents __ __ __ __ by individual patient & represents business record of org. | show 🗑
|
||||
| refers to all activities related to managing healthcare services provided to patient | show 🗑
|
||||
| show | care management
🗑
|
||||
| show | patient care support services
🗑
|
||||
| show | payment; reimbursement
🗑
|
||||
| are trended to assist in managing & reporting costs | show 🗑
|
||||
| show | primary user
🗑
|
||||
| education, research, regulation, & policy making are all considered __ __ of health record by Institute of Medicine (IOA) | show 🗑
|
||||
| were added to IOA list of secondary purposes of health record in 2003 | show 🗑
|
||||
| We had 324 Medicare patients last month. This statement represents | show 🗑
|
||||
| I am a patient. My medical history incl. info from my physicians & myself is stored on the Internet. This is an example of | show 🗑
|
||||
| show | patient care management
🗑
|
||||
| show | communication between caregivers
🗑
|
||||
| show | this is false; PHR controlled by patient & EHR controlled by provider
🗑
|
||||
| show | document patient care
🗑
|
||||
| show | IOM definition of health record users
🗑
|
||||
| __ __ of health records influence clinical care in some way, but they use info from health records for various reasons & in different ways | show 🗑
|
||||
| document their services directly in their patients' health records | show 🗑
|
||||
| submit separate written reports that become part of individual health record | show 🗑
|
||||
| show | patient care manager
🗑
|
||||
| patient care __ are also responsible for overall evaluation of services rendered for their particular area of responsibility | show 🗑
|
||||
| show | patterns; trends
🗑
|
||||
| show | combined aggregate
🗑
|
||||
| show | improve
🗑
|
||||
| based on documentation in health record | show 🗑
|
||||
| show | bill; claim
🗑
|
||||
| some 3rd-party payers require billers to submit portions of health record along with claims because documentation __ need for services & fact such services were provided | show 🗑
|
||||
| show | HIPAA
🗑
|
||||
| use info based on health records of employee to determine extent & effects of occupational hazards, manage healthcare/disability insurance benefits, & ind. employee's disability claims must be supported by documentation in health record | show 🗑
|
||||
| show | attorneys for healthcare organizations
🗑
|
||||
| legal reps of physicians & their __ __ __depend of documentation in health records | show 🗑
|
||||
| show | mental competency
🗑
|
||||
| show | law enforcement officials
🗑
|
||||
| show | healthcare accreditation organizations
🗑
|
||||
| show | participating
🗑
|
||||
| show | key component
🗑
|
||||
| show | accreditation survey
🗑
|
||||
| example of institutional user of health record info | show 🗑
|
||||
| patient care manager & support staff are user that would | show 🗑
|
||||
| show | quality of health record information
🗑
|
||||
| to accomplish primary & secondary purposes of health record, data in it must be of __ __ | show 🗑
|
||||
| show | missing; incomplete
🗑
|
||||
| one of HIM professionals most important roles is to ensure that health record contains __ __ possible | show 🗑
|
||||
| show | four domains
🗑
|
||||
| show | data quality management model
🗑
|
||||
| show | intended; defined
🗑
|
||||
| show | accuracy of data
🗑
|
||||
| must have systems in place that identify each patient & support efficient access to info on each patient | show 🗑
|
||||
| authorized users of health record must be able to access info __ when & where they need it | show 🗑
|
||||
| show | record access
🗑
|
||||
| previous health records available when/where needed; dictation equip. accessible & working properly; transcription accurate, timely, & readily avail. to providers; comp. data-entry devices working properly & readily avail. to providers affect | show 🗑
|
||||
| access control is relatively straightforward; records stored in locked storage areas accessible to only auth. HIM staff | show 🗑
|
||||
| show | technology-based access control mechanisms
🗑
|
||||
| show | complete
🗑
|
||||
| patient ID, consents for treatment, advance directives, problem list, diagnoses, clinical history, diagnostic test results, treatments & outcomes, & conclusions/follow-up requirements must be included in | show 🗑
|
||||
| show | reliable data
🗑
|
||||
| data values are __ when the value of any given data element is same across applications & systems | show 🗑
|
||||
| related data items should also be __ | show 🗑
|
||||
| show | data inconsistencies
🗑
|
||||
| show | legitimate
🗑
|
||||
| show | unacceptable inconsistencies
🗑
|
||||
| because care/treatment rely on accurate & current data, essential characteristic of __ __ is timeliness of documentation/data entry | show 🗑
|
||||
| show | definition; acceptable values
🗑
|
||||
| yields accurate data collection | show 🗑
|
||||
| show | narrative text
🗑
|
||||
| EHRs provide opportunity to __ data precision | show 🗑
|
||||
| reason for collecting a data element must be __ to ensure __ of data collected | show 🗑
|
||||
| in paper-based health records, __ of narrative detail provided often limits __ of data & info | show 🗑
|
||||
| show | measurement criteria
🗑
|
||||
| show | access; balanced
🗑
|
||||
| show | flexible
🗑
|
||||
| designed to make data readily avail. & meaningful to those caring for patient | show 🗑
|
||||
| when designed appropriately, EHRs can be extremely flexible in way they __ & __ info | show 🗑
|
||||
| show | patient-identifiable health information
🗑
|
||||
| __ & __ are components of health record that will be improved in computer-based systems, EHRs | show 🗑
|
||||
| show | structure
🗑
|
||||
| data entered into computer-based system for storage from paper-based records is scanned in making the data __ & cannot be used for __ __ | show 🗑
|
||||
| show | vocabulary; code sets
🗑
|
||||
| show | standard forms
🗑
|
||||
| show | properly formatted
🗑
|
||||
| show | source-oriented, problem-oriented, & integrated
🗑
|
||||
| problem-oriented health record format organizes info about problems into | show 🗑
|
||||
| show | IOMs Committee on Improving Patient Record
🗑
|
||||
| show | source of truth
🗑
|
||||
| show | substantial waste, imprecision, & complexity
🗑
|
||||
| in 2003 IOM added results management, order entry, & order management to | show 🗑
|
||||
| show | paper-based
🗑
|
||||
| show | computerized provider order entry (CPOE)
🗑
|
||||
| show | results management
🗑
|
||||
| can review structured electronic data & alert practitioners before problems evident, instant access to pharmaceutical formularies, referral databases, & reference literature | show 🗑
|
||||
| physician received notification from EHR that patient’s lab had dangerously high value. example of | show 🗑
|
||||
| according to AHIMA data quality model, what is term used to describe how data translated into info | show 🗑
|
Review the information in the table. When you are ready to quiz yourself you can hide individual columns or the entire table. Then you can click on the empty cells to reveal the answer. Try to recall what will be displayed before clicking the empty cell.
To hide a column, click on the column name.
To hide the entire table, click on the "Hide All" button.
You may also shuffle the rows of the table by clicking on the "Shuffle" button.
Or sort by any of the columns using the down arrow next to any column heading.
If you know all the data on any row, you can temporarily remove it by tapping the trash can to the right of the row.
To hide a column, click on the column name.
To hide the entire table, click on the "Hide All" button.
You may also shuffle the rows of the table by clicking on the "Shuffle" button.
Or sort by any of the columns using the down arrow next to any column heading.
If you know all the data on any row, you can temporarily remove it by tapping the trash can to the right of the row.
Embed Code - If you would like this activity on your web page, copy the script below and paste it into your web page.
Normal Size Small Size show me how
Normal Size Small Size show me how
Created by:
lfrancois
Popular Medical sets