Reading...
Play button
Play button
Use LEFT and RIGHT arrow keys to navigate between flashcards;
Use UP and DOWN arrow keys to flip the card;
H to show hint;
A reads text to speech;
22 Cards in this Set
- Front
- Back
|
What is Health Information?
|
*Health data about a patient
*A record is created every time a patient receives any type of health care services *Records include: -Medical History(symptoms & diagnoses) -Results of examinations -Diagnostic test -Treatment plans |
|
|
How Data is Organized?
|
*Advances in technology have allowed us to move from paper based records to electronic medical records
*Accurate records promote good health care *Electronic records can reduce error by having information well organized *May reduce staffing needs |
|
|
Management of the Health Information
|
*Medical Record Technician or Health Information Technician organizes and evaluates information
*They ensure: -Records are complete -Records have been authenticated -Information has been entered into computer -Communicate with providers to clarify diagnoses or obtain additional information needed |
|
|
Using the Data
|
*Physician uses health information to provide quality and cognitive care to the patient
*important that the records are very accurate *health care organization gathers information on patients that are seen with the same type diagnosis *the research is then done for new medications, side effects or contra indications *3rd Party Payers use the information to determine whether claims should be paid *provides proof of the services with medically necessaries *the use of compliance verifying the high-quality healthcare is being provided to patients *make sure patients are being well cared for and they are getting a good quality healthcare |
|
|
Health Information Management Professionals
|
*Responsible for the development and administration
*Must have expertise in: -Health informatics -Knowledge of clinical medicine -Knowledge of the comupter based patient record -Coding and classifications systems -Quality and human resource management -Ethical, legal, regulatory and accrediting agency *Duties will vary with the size of the facility -Specialize in one area -Supervision of other technicians -Management of the department -Some may specailize in coding |
|
|
HIMSS
|
*Health Information and Management Systems Society
*Organization focused on providing global leadership for optimal use of healthcare information *Founded in 1961, 20,000+ individual members and 300+ corporate members *Vision:Advancing the best use of information and management systems field through knowledge sharing, advocacy, collaboration, innovation, and community affiliations |
|
|
High Quality Data
|
*Information is only as reliable as the person who entered it
*Health Information: Management of Strategic Resource identifies nine characteristics of quality healthcare: 1. Validity 2. Reliability 3. Completeness 4. Recognizability 5. Timeliness 6. Relevance 7. Accessibility 8. Security 9. Legality |
|
|
Validity
|
*is synonymous with accuracy
*great care needs to be entered in with information that has any numeric value to that to avoid any transpositions of those characters *alpha characters are a little bit more readable *spellcheck can be used as far as transposition *numeric information can be very vaildle |
|
|
Reliability
|
*is something that we have to take into consideration that the person that is entering the information is accurate
*information also has to be trusted and rely on that in the numerical record |
|
|
Completeness
|
*Information is available in its entirety
*If servicess are provided and not documented, the record is considerable incomplete *Lack of vital information could be harmful to a patient |
|
|
Recognizability
|
*Individuals must be able to interpret the data documented in the record
*The data in understood by other users *Use caution when abbreviating *Legibility of handwriting |
|
|
Timeliness
|
*Information ideally should be entered immediately
*Information needs to be entered as soon as it is available *Refrain from committing things to memory to enter later *Decisions are made based on the latest data on the patient or treatment available *Diagnostic reports can determine patients prognosis or treatment plan |
|
|
Relevance
|
*information that is being entered into the patients record that is either relevant to the particular patient that is bound to be useful
*needless and meaningless information that does not benefit providers or doesn't benefit the individual using the health information should not be put in |
|
|
Accessibility
|
*based on the information being easily available to the provider when it is needed
*information can be accessed by more than one person at a time-Advantages of Electronical Medical Record *Paper Based Record processed as soon as things are filed and entered or the examination has been completed *they should be returned to the proper place as soon as poosible so those individuals in need of the patients individual can have access to the patients record |
|
|
Secruity
|
*Protect and secure paper medical records
*Ensure the use of firewalls and encryption for EMR *Make certain passwords are being protected *Allow access to authorized individuals for only information necessary for job completion |
|
|
Legality
|
*There a statutes that govern medical records
-Record retention -Correction of a record -Legibility and authentication -Use and disclosure of information |
|
|
HIPAA
|
*stands for the Health Insurance Portability and Accountability Act
*protects and support patient privacy issues *allows patients to control or access to their records along with other patient rights that they do have *the use of authorization, for use and disclosure of information, protected health information which is considered under the HIPAA law |
|
|
National Center for Health Statistics(NCHS)
|
*a division of the Centers for Diease Control and Prevention
*commonly known for CDC *primary provider of health information statistics |
|
|
Functions of NCHS
|
*Functions include:
-document the health status of the populations and subgroups -Identify disparities in health status and use of healthcare by race, ethnicity, socioecnomic status region and other population gradients -Descriptions of experiences with the healthcare system -Monitor trends in health status and healthcare delivery -Identify health problems -Give support for biomedical & health services research -Provide information to change public policies and programs -Evaluate the impact of health policies and programs |
|
|
Statistics Available thru NCHS
|
*Teen pregnancy
*Incidence of HIV infection *Alcohol and drug abuse *Births *Deaths *Communicable Diseases *Infant health and mortality *Leading causes of death *Life expectancy *Sexually transmitted Diease *Suicide |
|
|
JCAHO
|
*Joint Commission Accreditation of Healthcare Organizations
*nonprofit organization that provides accreditation services to healthcare facilities *the facility must set a standard that is set by this organization and must be able to prove that they are compliance of these standards *the goal is for the hospital itself to excide those standards to provide optimal healthcare to the patients |
|
|
Risk Management
|
*any occurrencethat could result in a patient becoming injured or financial lost to the facility
*there are policies and procedures in placed manangement risk and prevents situations lost or harmed *Sentinel Event- is an unexpected occurrence in deaths, serious physical or psychological injury or the risk thereof *it needs to be investigated thoroughlyand making sure everything has been taking care of in a proper manner |
