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201 Cards in this Set
- Front
- Back
Accredited facility granted certification and therefore eligible to receive Medicare funds has
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Deemed status
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The test that is done on newborns at 1 and 5 minutes after birth
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APGAR Score
Score up to 10. Higher the number the better the score. |
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APGAR Score tests what 5 things?
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Heart rate
Muscle tone Respiration's Reflex Color |
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Professional organization for managers of health record services and healthcare information
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American Health Information Management Association (AHIMA)
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Discharge Summary is also known as a?
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Clinical Resume
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According to the Joint Commission standards a H&P interval note is acceptable in what time frame?
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30 Days
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The diagnosis, after study that is chiefly responsible for the patients admission
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Principal or Primary
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The limitation of the use and disclosure of private information
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Confidentiality
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If a Hospitals records are kept by each different department, what type of filing is this called
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Decentralized
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The numbering system that generates a new number for each visit or encounter
Numbers are issued in a series Separate health records Inefficiencies |
Serial
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Services that are given in a doctor’s office are called
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Ambulatory or OP
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An undesirable and serious occurrence in patient care
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Sentinel Event
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The type of data that is recorded in the patient record
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Primary
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Means that data is easy to obtain
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Accessibility
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Institutional Users or External users of data
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Accreditation organizations
Licensing bodies Educational organizations Third-party payers Research facilities Those who need the information in the health record to perform various kinds of analyses |
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Individual Users
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Patient care providers
Patient care managers and support staff Coding and billing staff Patients Employers Lawyers Law enforcement officials Healthcare researchers and clinical investigators Health science publishers and journalists Government policy makers Primary users are patient care providers Those who need to use the health record to perform their jobs |
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All the data elements that are required are present
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Completeness
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Data capture technology
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Bar Code Reader
OCR Voice Recognition |
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Agency that accredits rehabilitation facilities
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CARF
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JC requirement for the number of delinquent records that a facility cannot exceed
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No more than 50% AMD
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The maximum time frame that JC or HFAP/AOA will accredit a facility
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3 years
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Delinquent medical record statistics must be calculated at a minimum
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Quarterly
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OSHA’s space requirement for primary aisles
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60”
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The microfilm that has the greatest storage density and the system that records the location of health records
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Roll Film
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Write Once Read Many (WORM)
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Describes a data storage device in which information, once written, cannot be modified. This write protection affords the assurance that the data cannot be tampered with once it is written to the device.
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Errors are corrected as follows:
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Single line drawn in ink through incorrect entry
Print word error at top of entry along with signature (or initials) Document date, time and reason for change Record correct information Must be able to read error Late entries must be labeled as such |
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Computer Output to Laser Disk (COLD)
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Used to capture, archive, store, and retrieve large-volume data
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“SOAP” is used in recording
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Progress notes
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The record prepared in physician office setting that should be made part of every obstetrical record
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Antepartum Record
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According to the AOA, abbreviations are not acceptable on what form
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Facesheet
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The document that indicates who can receive and transcribe verbal and telephone orders
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Medical Staff Bylaws
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RHIA hours within a reporting cycle
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30
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RHIA/RHIT hour reporting cycle
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2 years
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RHIT hours within a reporting cycle
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20
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Responsible for the day to day operations of AHIMA
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Executive Director and staff
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The process by which an HIM professional gains recognition for professional competence
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Certification
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Oversees accreditation of college programs
Independent accreditation organization Establishs quality standards |
Commission on Accreditation of Health Informatics and Information Management (CAHIIM) Education
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The application of ethical principles to decisions that affect human lives
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Bioethics
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The right of individual patients to determine what healthcare services they do or do not undergo
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Autonomy
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The promotion of good for others or the provision of helpful services for others
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Beneficence
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Given the competing interests and limited resources of the parties involved, the consideration of fairness to those affected by decisions
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Justice
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The principle that requires that one party must do no harm to another
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Nonmaleficence
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Requirements must be followed for Medicare and Medicaid patients
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COP – Certification
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According to the Conditions of Participation a patient’s health record must be retained
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5 years
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Three sets of standards that should govern the contents of a medical record
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Accreditation
Certification Licensure |
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Michigan state guidelines for hospitals
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Rules and Minimum Standards
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Time frame in which medical records must be completed according to AOA and JC
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30 days
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Document that governs the Medical Staff
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Bylaws
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Difference between data and information
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Data is facts, Information is meaning
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Care/rest for the caregiver
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Respite care
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SOAP Format Example
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S=Subjective: Initially is the patient's Chief Complaint
O=Objective: Vital signs and measurements, such as weight. A=Assessment: medical diagnosis for the purpose of the medical visit P=Plan: what the health care provider will do to treat the patient's concerns |
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A review of the health record to determine its completeness and accuracy
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Quantitative Analysis
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The right of an individual to be let alone
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Privacy
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Provides a language and a framework for formally discussing ethical issues, taking into account the values and obligations of others
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Ethics
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There is more than one possibility for what the diagnosis is and they must differentiate between these to determine what the principal and secondary diagnoses are.
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Differential Diagnoses
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Contains pertinent demographic data on patient
**Permanent record of every patient treated at healthcare facility-Basic information *Patient name (last, first, middle) *Health record number (most important part) *Date of birth *Gender *Dates of encounter |
Master Patient Index
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MOST COMMON-Recommended
Commonly used in large healthcare facilities Unique health record number assigned at first visit and retained for all subsequent visits Patient encounters are linked together Search is usually based on patient account number or patient name |
Unit numbering system
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New health record number assigned each visit
Records brought forward into newest number Most difficult to gauge-for shelving |
Serial-unit numbering system
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Identification Systems for Paper-based Health Records
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Serial numbering system
Unit Numbering Example Serial-unit Numbering |
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Requires a Master patient index
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Numeric Filing System
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Based on patient’s last name
Date of birth is used when more than one person with same name Effective with small volume of records Usually seen in small physician practice Disadvantages No unique identifier Does not expand evenly Time-consuming to purge files |
Alphabetic identification and filing system
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Consecutively filed
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Straight numeric filing systems
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Most efficient
Used with heavy record volume Allows even file expansion |
Terminal-digit filing system
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Combination of letters and numbers
First two letters of last name plus unique numeric identifier Appropriate for small organizations |
Alphanumeric Filing Systems
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OSHA floor and aisle space requirements for secondary aisle's
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36”
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Records removed from file area if inactive for specified period
Purged records may be microfilmed, stored off-site or scanned Timing depends on o Space o Patient readmissions o Use of patient record data |
Purging Inactive Records
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Used to aid in the prevention of misfiles
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File folders-Color coded
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Continuous length of microfilm around a spool
File integrity guaranteed (impossible to alter the film) Least expensive with greatest storage (hard to update) |
Roll microfilm
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A roll of microfilm is cut and placed into special four-by-six-inch jackets with several sleeves to hold the images
Unit record |
Jacket microfilm
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Transparent rectangle of film containing micro images filmed directly on to film
A card or sheet of microfilm capable of accommodating and preserving a considerable number of pages, as of printed text, in reduced form. |
Microfiche
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Data are reliable
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Consistency
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Data should be up-to-date
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Currency and timeliness
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Data are correct
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Accuracy
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All required data elements included
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Comprehensiveness
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Data and information is defined-Each data elements defined and range of acceptable values
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Definition
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Attributes and values of data defined at correct level of detail for the intended use
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Granularity
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Expected data values
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Precision
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Data are useful
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Relevancy
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When can an Interval Note (updated history) take the place of a new history and physical
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If a patient is readmitted within a month (30 days) of discharge for the same condition at the same hospital
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Used when paper-based records are checked out
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Outguide
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Request for a health record from another department
o Paper or electronic |
Requisition
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o Include both paper and electronic documents
o Use both manual and electronic processes o Difficult to locate all components of the record |
Hybrid records
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Record is completely electronic
o Contains clinical decision support |
Electronic records
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Admitting or working diagnosis
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Provisional Diagnosis
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OB Documentation (moms chart)
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o Prenatal information
o Comprehensive personal and family history o Detailed physical exam o Treatment Plan o Patient Instructions o Postpartum Information o Discharge summaries are not required for normal deliveries, a discharge progress note is sufficient o Labor and delivery record takes the place of an operative report for normal deliveries o Must be on hospital medical record by the 36th week |
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Newborn Documentation
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o Newborn health records are maintained separately from their mothers records
o In normal deliveries, duplicates much of the information in the mothers record o Premature infants and others who require ICU after birth require full documentation o Facility specific polices on fetal demise cases o APGAR scoring |
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Record put on some form of other storage medium
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Inactive
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Active File Storage
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No retention guidelines in Michigan, regulatory agencies is 5 years. May be stored off site in paper format
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Charts are all kept in one location
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Centralized
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Mission is to accelerate adoption of health information technology
One of six organizations that can certify EHRs Certifies health information technology |
Certification Commission for Health Information Technology (CCHIT)
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Verbal or Telephone Orders
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State law and medical staff rules specify which practitioners are allowed to accept and execute verbal and telephone orders
Must be signed within 24 hours by the provider who gave the order |
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Diagnostic and Therapeutic Orders
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Verbal or Telephone Orders
Standing or Routine Orders Special Orders |
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Standing or Routine Orders
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Orders the medical staff or an individual physician has established as routine care for a specific diagnosis or procedure
Commonly used in hospitals, ambulatory surgery centers, and long term care facilities Usually, preprinted on a single sheet of paper or available via a standard computer screen |
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Special Orders
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Do Not Resuscitate (DNR)
Use of seclusion or restraints All types must be signed and dated |
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Hospital Standardization was initiated by
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American College of Surgeons
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Oversees certification process
Establishes, implements, and enforces standards and procedures for certification and recertification |
Commission on Certification for Health Informatics and Information Management (CCHIIM)
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Functions as legislative body
Establishes mission and goals Develops policies and procedures-Approving standards-Approving amendments to AHIMA’s bylaws Provides oversight for organization’s operations Members elected by state HIM association |
AHIMA House of Delegates (Volunteer Structure)
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Lead the volunteer structure and approve the budget, set the direction for AHIMA, set the goals
o President o President-elect o Past president o Directors (9 o Executive director |
AHIMA Board of Directors (Heads Volunteer Structure)
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o Carries out operational tasks to support the mission and goals
o Works within policies established by volunteer component |
AHIMA Staff
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AHIMA is located in
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Chicago
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Principal repository for data and information about healthcare services provided to the individual patient
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Health record
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Primary purpose is related directly with the provision of patient care services
Secondary purposes are related to the environment in which the healthcare services are performed |
Purposes of Health Record
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Names for the Health Record
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Client records – ambulatory behavioral health services
Patient records – inpatient setting Medical record – physician office Resident – long-term care |
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Nature and duration of the symptoms that caused the patient to seek medical attention as stated in his or her own words
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Chief Complaint
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Functions of Health Record
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Store patient care documentation created by various different disciplines involved with the patients care
Other functions: Assist in assigning diagnoses Assist in choosing treatment |
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Paper Records
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Source-oriented health record format
Problem-oriented health record format Integrated health record format |
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Notify physicians of abnormal test results
Assist in diagnosing and selecting treatment Access to reference materials such as pharmaceutical formularies Analyze data |
Clinical decision support
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Documents are grouped together based on point of origin (according to patient care department)-Labs with Labs, Radiology with Radiology
Reports in each section may be in chronological or reverse chronological order Advantages Very organized for each department to locate section for documentation-Easy for adding loose papers Disadvantages Cannot determine all the patient’s problems and treatment quickly-Must look in each area of the chart which is timely |
Source-oriented
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Itemized list of patient’s past and present social, psychological, and medical problems
Each problem is indexed with unique number (problem list) Better suited to serve the patient and the end user of the patient information Advantages: o Examining all of patient’s problems o Good training tool for house staff Disadvantages: o Requires additional training o Takes a lot of time to complete |
Problem-oriented
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Table of contents for patients care
List of anything that requires management or diagnostic workup Each problem is numbered, titled and dated As each problem is resolved it is marked off-usually dropped off list or resolved is written and dated behind |
Problem List
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Four sections of Problem-oriented Record
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Database
Problem list Plan Progress notes |
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Documentation from various sources is intermingled and follows strict chronological order
Advantages: o Easy to follow the course of the patient’s diagnosis and treatment Disadvantages: o Difficult to compare similar information |
Integrated
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Six Sections of a History
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Chief complaint
-Present illness -Social history -Medical history -Physical examination -Diagnostic test results |
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Documents medical condition, diagnoses, procedures, and treatment
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Clinical data
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Demographic and financial information
Consents and authorization |
Administrative data
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Types of Consent
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Implied Consent
Expressed Consent Consent to Treatment |
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Consent for Treatment-Clinical
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Nature of treatment
Risks Complications Alternative forms of treatment Consequences of treatment |
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Advanced Directives
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Written document that names the patient’s choice of legal representative for healthcare purposes
Living Wills Durable Power of Attorney for Healthcare Services |
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A summary of the patient’s illness from his or her point of view
Completed and on the chart with in 24 hours of admission or before surgery For planned admissions, the physical exam may also be performed within 7days before admission |
History
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Face Sheet Names
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Admit and Discharge Record
Registration Record Admission Summary Sheet |
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Interval Notes MUST Include
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Information about the patient’s current complaint
any relevant changes in condition, physical findings since last admission |
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First order required in all inpatient charts
-Filled out by physician who admitted the patient |
Admission Order
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Last required order in the chart unless patient leaves Against Medical Advice (AMA)
-Completed by the attending physician who discharged the patient |
Discharge Order
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Types of Progress Notes
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Admission Note
Daily Notes Integrated Progress Notes Nursing Notes Discharge Note |
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First note written once the patient is admitted to a specific unit
-Gives a brief overview of patient and current conditions |
Admission Note
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Progress notes are normally written daily by professionals but frequency can vary by patient condition
-Written by multiple disciplines (integrated) |
Daily Progress Notes
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Final note written by physician that includes the condition on discharge, instructions related to diet, activity, medications and follow up
-Nursing will use for final discharge work up for patient prior to leaving facility |
Discharge Note
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Summary statement to document the circumstances surrounding the patient’s death
Includes: Reason for the patient’s admission Diagnosis Course in the hospital A description of the events that led to the death |
Death Note
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Documents the clinical opinion of a physician other than the primary or attending physician
-Requested by primary or attending normally documented in physician orders or progress notes -Based on consulting physician’s exam of the patient and a review of the patient health record |
Consultation Reports
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When to Consider a Consultation
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Patient is not a good risk for a procedure
Unclear diagnosis and need some further investigation Best method of treatment difficult to determine Question of criminal activity with relation to the current injury To rule out conditions |
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Admission Nursing Assessment
Care Plans Progress Notes Medication Records Flow Charts Transfer Records (Referral Form) |
Nursing Documentation
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Provide a complete record of the patient’s care and response to treatment and gives a complete picture
-Every 8 hours a complete assessment of the patient’s condition is documented |
Nursing Progress Notes
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Flow Charts-Vital signs are recorded
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Every 2 hours
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Concise account of the patient’s illness, course of treatment, response to treatment and conditions at time the patient is discharged from the hospital
-The physician who writes the discharge order is responsible for generating the summary -Normally located at the front of the record behind the face sheet |
Discharge Summary
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A discharge note instead of a full summary can be utilized if:
1. the patient’s stay is not complicated and last less than 48 hours OR 2. the patient’s stay involves an uncomplicated delivery or normal newborn |
Discharge note
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Tracks patient from admissions through delivery to postpartum
Shows data for 3 stages of labor 1. Contraction data 2. Membrane Data 3. Any Bleeding Present |
Labor and Delivery Records
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Not Part of the Medical Record
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Incident Reports
Billing and Financial Information Peer Review Documents |
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Any occurrence that is not consistent with the routine operation of the hospital or a situation that has risk management implications requires an
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Incident Reports
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Peer Review Committee meeting minutes are kept permanently and confidentially in medical staff or administrative offices
Utilization Review Worksheets |
Peer Review Documents
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Graphic Record
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Vitals
Weight Intake Output |
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Special Orders
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Do Not Resuscitate (DNR)
Use of seclusion or restraints o All types must be signed and dated |
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Orders the medical staff or an individual physician has established as routine care for a specific diagnosis or procedure
Commonly used in hospitals, ambulatory surgery centers, and long term care facilities Usually, preprinted on a single sheet of paper or available via a standard computer screen |
Standing or Routine Orders
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The business record generated at or for a healthcare organization.
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Legal EHR
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Data about data
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Metadata
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Security Elements of a Legal EHR
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Audit Trails
Metadata Versioning Alterations |
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How to authenticate a user
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By something the user knows (password)
By something the user has (computer token) By something the user provides (a written signature or fingerprint) |
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The access, use and prevention of information, data and records created or maintained in electronic media.
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E-Discovery
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The process to suspend normal destruction when there is a reasonable anticipation of litigation to prevent spoilage of evidence.
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Legal Hold
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Protect patient privacy, security, and confidential information and communication
Ensuring completeness, accuracy, integrity and timeliness of health information Comply with laws, regulations, standards, and policies from many sources |
Core ethical responsibilities of HIM professionals
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Primary care person is the one who coordinates the health for a home care hospice patient (patient’s nurse)
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Hospice
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Put on some form of other storage medium
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Inactive
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No retention guidelines in Michigan, regulatory agencies is 5 years. May be stored off site in paper format.
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Active File Storage
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Mission to promote science and art of medicine and to improve public health
Accredits medical schools and residency programs Maintains and publishes Current Procedural Terminology |
American Medical Association (AMA)
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Average length of stay in acute care hospital
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30 days or less
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Hospitals Can Be Classified By
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Number of beds
Types of services provided Types of patients serviced For-profit or not-for-profit status Type of ownership |
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Primary responsibility for setting direction of hospital
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Hospital Board of Directors
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Process of evaluating the efficiency and appropriateness of healthcare services
1. Prospective-prior to services 2. Concurrent-during the services 3. Retrospective-after services |
Utilization Review
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State
Required to operate Standards |
Licensure
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Conditions of Participation
Standards Deemed status |
Certification for Medicare Participation
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An electronic record of health-related information on an individual within one health organization
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Electronic medical record
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An electronic record of health-related information on an individual across more than one healthcare organization
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Electronic health record
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American National Standards Institute (ANSI) accredited organization who provides standards for the exchange, integration, sharing, and retrieval of electronic health information
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Health Level Seven (HL7)
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Ability to exchange data among information systems
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Interoperability
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Nonrepudiation can be obtained through the use of
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Digital signatures
Confirmation services Timestamps |
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Scanned image of a “wet” signature; weak because someone can acquire a copy of the image and use it
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Digitized signature
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Cryptographic signature that authenticates the user
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Digital signature
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Application of password to an electronic document
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Electronic signature
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Buy the best system for the specific function, thus systems are coming from many vendors
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Best of breed
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Buy systems for hospital from a single vendor
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Best of fit
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Expensive and massive undertaking, but
May be best way to achieve desired results efficiently and effectively |
Rip and replace
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Who issues licenses for Michigan healthcare facilities?
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The State
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Which organization issues licenses for Michigan healthcare facilities?
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Michigan Consumers & Industry Services, Bureau of Health Services
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Does a facility have to be licensed?
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It is mandatory to operate.
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What must a facility be in compliance with to be licensed?
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Must be in compliance with Michigan Rules and Minimum Standards for Hospitals
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How often must a facility be reviewed for licensing?
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Annually-usually completed at the same time as certification surveys
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The approval of the state to build or expand health care facilities and services
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Certificate of Need- State Issued
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Granted to all healthcare facilities that are in substantial compliance with Federal Regulations governing each type of health care setting
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Certification
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Certification is granted by?
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The Center for Medicare and Medicaid Services-based on the findings of Michigan Consumers & Industry Services, Bureau of Health Services and Accreditation Agencies
|
|
Regulations for health care institutions are found in the federal register
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Conditions of Participation
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Does a facility have to have Accreditation?
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Voluntary participation by hospitals
Financial and legal incentives to attain accreditation |
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Accreditation is required for?
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Required for reimbursement for certain patient groups including Medicare and Medicaid
|
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Once an organization is found to be in substantial compliance with Joint Commission Standards accreditation may be awarded for up
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3 years
|
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Hospitals must undergo a full survey at least
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Every 3 years
|
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The Joint Commission will give organizations an opportunity to avoid dates per year.
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10 dates per year
|
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End of life care
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Palliative Care
|
|
AOA Scoring
|
1. Full Compliance
2. Essential Compliance 3. Marginal Compliance 4. Non-Compliance NA-Not Applicable |
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Individuals who receive acute-care services in a hospital are considered
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Inpatients
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Ambulatory surgery does not require
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An overnight stay in a hospital
|
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Primarily responsible for monitoring the daily operations of an entire health care organization
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Chief executive officer
|
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Responsible for implementing the policies and strategic direction of the hospital or healthcare organization on daily basis and building an effective executive management team
|
Chief executive officer
|
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Has the responsibility of setting the overall direction of the hospital
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Board of Directors
|
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Primary focus of AHIMA
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Promote/provide professional development of its members
|
|
Discrete data are entered into the EHR via
|
Templates
Macro Point and Click Voice Command |
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Web page that offers secure access to data
|
Portal
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Interface is
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Program to exchange data
|
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Step by step approach to installing, testing, training and gaining adoption for an EHR is
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Implementation Plan
|
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Security of an EHR is afforded via
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Access controls
|
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Ensures accurate and timely data entry
|
Data Quality
|
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An ideal EHR system is one that requires point of care charting
|
Supports clinical decision making
|
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Types of Filing Systems
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Straight numeric filing systems
Terminal-digit filing system Middle-digit filing system Alphanumeric Filing Systems |
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A review of the health record to ensure that standards are met and to determine the adequacy of entries documenting the quality of care
|
Qualitative Analysis
|