Intro To Him Profession

Front 1

What does the Health Record Contain?

Back 1

Contains Information relating to the physical or mental health or condition of an individual as made by or on behalf of a health professional in connection with the care ascribed that individual

Front 2

What is the difference between dataand information of the Health Care Record?

Back 2

Data: Raw facts and figures

Information: data that has been turned into somethingmeaningful.

In other words, data arebasic facts with no meaning in and of themselves – dates, numbers, text,checklists, images, etc; while information is the meaningful use of data that hasbeen collected, analyzed, & converted into usable form

Front 3

Whatis the difference between primary and secondary purposes of the Healthcare Record?

Back 3

Primary: Related to providingpatient care. Direct care provided andthe day to day business of the organization.

Secondary: For the most part, the patient name is associated with the healthrecord in primary uses; it is redacted for secondary uses.

Front 4

Primary Purposes of Healthcare Record

Listthe 3 primary purposes

Back 4

Patient Purpose

Management Purpose

Administrative Purpose

Front 5

Primary Purposes of Healthcare Record :

Patient Purpose Defined

Back 5

documentscare provided by physicians, nurses, and allied health professionals; serves asa communication tool between professionals; contains treatments and responsesto treatments

Front 6

Primary Purposes of Healthcare Record:

Management Purpose Defined

Back 6

development of patient care standards,conducting research, evaluating quality of care provided

Thisincludes all activities related to managing the healthcare services provided topatients, analyzing illness, and formulating practice guidelines

Front 7

Primary Purposes of Healthcare Record:

Administrative Purpose Defined

Back 7

billing for services, making decisionsabout the future of the healthcare facility, monitoring fiscal health of theorganization, scheduling staffing

Front 8

Secondary Purposes of the Health Care Record Defined:

Back 8

Secondarypurposes are related to environment inwhich patient care is provided.

Front 9

List 3 Secondary Purposes of the Health Record

Back 9

. Education of healthcare professionals

. Legal Accreditation and Policy Development . . . Public Health and Research

Front 10

FORMATS OF THE HEALTH RECORD

List 3 Formats of the Health Record

Back 10

1. Paper

2. Electronic

3. Hybrid

Front 11

Users of the Health Record:

Who are the Primary Users of the Health Record?

Back 11

Healthcare Providers

Front 12

Users of the Health Record:

What is "Aggregate" Data?

Back 12

Data that has beenextracted from individual health records and combined to form deidentifiedinformation about groups of patients that can be compared and analyzed

Front 13

Individual Users of Health Record

Name 9 Individual Users of Health Records

Back 13

1. Patient Care Providers

2. Patient Care Managers and Support Staff

3. Coding and Billing Staff

4. Patients

5. Employers

6. Lawyers

7. Law Enforcement Officials

8. Healthcare Researchers and Clinical

Investigators

9. Government Policy Makers

Front 14

Individual Users of Health Record

Patient Care Providers Defined

Back 14

To make decisions about the care provided to a patient

Front 15

Individual Users of Health Record:

Patient Care Managers and Support Staff Defined

Back 15

Toevaluate thequality of care provided, and to identify patterns and trends to recommendchanges to patient care processes to improve outcomes and efficiency.

Front 16

Individual Users of Health Record:

Billing Staff Defined

Back 16

Touse health record documentation for reimbursement or payment for careprovided.

Front 17

Individual Users of Health Record:

Coding Staff Defined

Back 17

To read the record and assign appropriate codes for diagnoses and procedures,which are used to generate a bill or insurance claim.

Front 18

Individual Users of Health Record:

Patients Defined

Back 18

Asinformed consumers, obtain access to and be informed about their health record

Front 19

Individual Users of Health Record:

Employers Defined

Back 19

To processhealth insurance claims and manage wellness programsbody

Front 20

Individual Users of Health Record:

Lawyers Defined

Back 20

To supportfor clients' claims and lawsuits

Front 21

Individual Users of Health Record:

Law Enforcement Officials

Back 21

Forinvestigations of injuries resulting from criminal activity and informationconcerning security of the country

Front 22

Individual Users of Health Record:

Healthcare Researchers and Clinical Investigators

Back 22

To study safety and efficacy of drugsand value of care provided; approve new treatments; stop unsafe treatments

Front 23

Individual Users of Health Record:

Government Policy Makers

Back 23

Toevaluate current and future laws, regulations, and standards related tohealthcare

Front 24

Institutional Users Of Health Record:

Howdo health care delivery organizations use data from health records?

Back 24

To provide care, submitclaims for reimbursement, and evaluate the quality of care provided

Front 25

How do third party payers use health recordinformation?

Back 25

To justify the care providedand therefore the reimbursement

Anactual review is sometimes performed by medical review organizations.

Front 26

How do medical review organizations use thehealth record?

Back 26

Evaluate the quality andappropriateness of the care provided to the patient.

Determine if the care provided to the patient was medically necessary.

Somereview organizations determine whether services are medically necessary.

Front 27

Name 2 types of medical review organizations

Back 27

Quality Improvement organizations

Utilization Management organizations.

Front 28

Name 2 types of reviews that can occur

Back 28

concurrentand retrospective

Front 29

Concurrent Review Defined

Back 29

Review that takes place while the patient is still in the hospital

Front 30

Retrospective Review

Back 30

Review that occurs after the patient has been discharged

Front 31

How do research organizations use informationfrom health records?

Back 31

Conduct medical research and include state disease registries suchas cancer registry research centers and otherswho explore diseases and their treatments

Front 32

List some educational organizations that utilizehealth records for case study information.

Back 32

Colleges, Universities trainhealth care professionals in their medical schools as well as nursing and allied health programs

Front 33

How are health records used by the accreditingorganizations?

Back 33

Review of the health recordin order to ensure compliance with state licensing requirements and inverifying compliance with documentation and patient care standards This is done to make overall accreditation decisions. Themission of accreditation organizations is to improve the quality ofservices offered in the health care facility. Accreditation is voluntary.

Front 34

How are health records used by governmentlicensing agencies?

Back 34

Review the health record inorder to ensure compliance with state licensing requirements and in verifyingcompliance with standard that enable the healthcare facility to receivefederal funding

State licensure is mandatory. All licenses come from the individual state.

Front 35

What do the letters CMS stand for?

Back 35

Centers for Medicare andMedicaid Services

Front 36

What does the CMS do with information fromhealth records?

Back 36

Utilizes a wide range ofdata to make revisions to reimbursement systems each year The CMS administers the federal Medicare program and the federalportion of the Medicaid program. Theinformation from health records is also used to determine the effectiveness ofhealthcare services, and to determine the general health of the Medicarepopulation. Similar information databases are maintainedat the state level.