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201 Cards in this Set

  • Front
  • Back
Accredited facility granted certification and therefore eligible to receive Medicare funds has
Deemed status
The test that is done on newborns at 1 and 5 minutes after birth
APGAR Score

Score up to 10. Higher the number the better the score.
APGAR Score tests what 5 things?
Heart rate
Muscle tone
Respiration's
Reflex
Color
Professional organization for managers of health record services and healthcare information
American Health Information Management Association (AHIMA)
Discharge Summary is also known as a?
Clinical Resume
According to the Joint Commission standards a H&P interval note is acceptable in what time frame?
30 Days
The diagnosis, after study that is chiefly responsible for the patients admission
Principal or Primary
The limitation of the use and disclosure of private information
Confidentiality
If a Hospitals records are kept by each different department, what type of filing is this called
Decentralized
The numbering system that generates a new number for each visit or encounter

Numbers are issued in a series
Separate health records
Inefficiencies
Serial
Services that are given in a doctor’s office are called
Ambulatory or OP
An undesirable and serious occurrence in patient care
Sentinel Event
The type of data that is recorded in the patient record
Primary
Means that data is easy to obtain
Accessibility
Institutional Users or External users of data
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
Individual Users
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
All the data elements that are required are present
Completeness
Data capture technology
Bar Code Reader
OCR
Voice Recognition
Agency that accredits rehabilitation facilities
CARF
JC requirement for the number of delinquent records that a facility cannot exceed
No more than 50% AMD
The maximum time frame that JC or HFAP/AOA will accredit a facility
3 years
Delinquent medical record statistics must be calculated at a minimum
Quarterly
OSHA’s space requirement for primary aisles
60”
The microfilm that has the greatest storage density and the system that records the location of health records
Roll Film
Write Once Read Many (WORM)
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.
Errors are corrected as follows:
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
Computer Output to Laser Disk (COLD)
Used to capture, archive, store, and retrieve large-volume data
“SOAP” is used in recording
Progress notes
The record prepared in physician office setting that should be made part of every obstetrical record
Antepartum Record
According to the AOA, abbreviations are not acceptable on what form
Facesheet
The document that indicates who can receive and transcribe verbal and telephone orders
Medical Staff Bylaws
RHIA hours within a reporting cycle
30
RHIA/RHIT hour reporting cycle
2 years
RHIT hours within a reporting cycle
20
Responsible for the day to day operations of AHIMA
Executive Director and staff
The process by which an HIM professional gains recognition for professional competence
Certification
Oversees accreditation of college programs
Independent accreditation organization

Establishs quality standards
Commission on Accreditation of Health Informatics and Information Management (CAHIIM) Education
The application of ethical principles to decisions that affect human lives
Bioethics
The right of individual patients to determine what healthcare services they do or do not undergo
Autonomy
The promotion of good for others or the provision of helpful services for others
Beneficence
Given the competing interests and limited resources of the parties involved, the consideration of fairness to those affected by decisions
Justice
The principle that requires that one party must do no harm to another
Nonmaleficence
Requirements must be followed for Medicare and Medicaid patients
COP – Certification
According to the Conditions of Participation a patient’s health record must be retained
5 years
Three sets of standards that should govern the contents of a medical record
Accreditation
Certification
Licensure
Michigan state guidelines for hospitals
Rules and Minimum Standards
Time frame in which medical records must be completed according to AOA and JC
30 days
Document that governs the Medical Staff
Bylaws
Difference between data and information
Data is facts, Information is meaning
Care/rest for the caregiver
Respite care
SOAP Format Example
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
A review of the health record to determine its completeness and accuracy
Quantitative Analysis
The right of an individual to be let alone
Privacy
Provides a language and a framework for formally discussing ethical issues, taking into account the values and obligations of others
Ethics
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.
Differential Diagnoses
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
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
New health record number assigned each visit
Records brought forward into newest number
Most difficult to gauge-for shelving
Serial-unit numbering system
Identification Systems for Paper-based Health Records
Serial numbering system
Unit Numbering Example
Serial-unit Numbering
Requires a Master patient index
Numeric Filing System
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
Consecutively filed
Straight numeric filing systems
Most efficient
Used with heavy record volume
Allows even file expansion
Terminal-digit filing system
Combination of letters and numbers
First two letters of last name plus unique numeric identifier
Appropriate for small organizations
Alphanumeric Filing Systems
OSHA floor and aisle space requirements for secondary aisle's
36”
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
Used to aid in the prevention of misfiles
File folders-Color coded
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
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
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
Data are reliable
Consistency
Data should be up-to-date
Currency and timeliness
Data are correct
Accuracy
All required data elements included
Comprehensiveness
Data and information is defined-Each data elements defined and range of acceptable values
Definition
Attributes and values of data defined at correct level of detail for the intended use
Granularity
Expected data values
Precision
Data are useful
Relevancy
When can an Interval Note (updated history) take the place of a new history and physical
If a patient is readmitted within a month (30 days) of discharge for the same condition at the same hospital
Used when paper-based records are checked out
Outguide
Request for a health record from another department
o Paper or electronic
Requisition
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
Record is completely electronic
o Contains clinical decision support
Electronic records
Admitting or working diagnosis
Provisional Diagnosis
OB Documentation (moms chart)
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
Newborn Documentation
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
Record put on some form of other storage medium
Inactive
Active File Storage
No retention guidelines in Michigan, regulatory agencies is 5 years. May be stored off site in paper format
Charts are all kept in one location
Centralized
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)
Verbal or Telephone Orders
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
Diagnostic and Therapeutic Orders
Verbal or Telephone Orders
Standing or Routine Orders
Special Orders
Standing or Routine Orders
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
Special Orders
Do Not Resuscitate (DNR)
Use of seclusion or restraints
All types must be signed and dated
Hospital Standardization was initiated by
American College of Surgeons
Oversees certification process

Establishes, implements, and enforces standards and procedures for certification and recertification
Commission on Certification for Health Informatics and Information Management (CCHIIM)
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)
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)
o Carries out operational tasks to support the mission and goals
o Works within policies established by volunteer component
AHIMA Staff
AHIMA is located in
Chicago
Principal repository for data and information about healthcare services provided to the individual patient
Health record
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
Names for the Health Record
Client records – ambulatory behavioral health services
Patient records – inpatient setting
Medical record – physician office
Resident – long-term care
Nature and duration of the symptoms that caused the patient to seek medical attention as stated in his or her own words
Chief Complaint
Functions of Health Record
Store patient care documentation created by various different disciplines involved with the patients care
Other functions:
Assist in assigning diagnoses
Assist in choosing treatment
Paper Records
Source-oriented health record format
Problem-oriented health record format
Integrated health record format
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
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
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
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
Four sections of Problem-oriented Record
Database
Problem list
Plan
Progress notes
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
Six Sections of a History
Chief complaint
-Present illness
-Social history
-Medical history
-Physical examination
-Diagnostic test results
Documents medical condition, diagnoses, procedures, and treatment
Clinical data
Demographic and financial information
Consents and authorization
Administrative data
Types of Consent
Implied Consent
Expressed Consent
Consent to Treatment
Consent for Treatment-Clinical
Nature of treatment
Risks
Complications
Alternative forms of treatment
Consequences of treatment
Advanced Directives
Written document that names the patient’s choice of legal representative for healthcare purposes

Living Wills
Durable Power of Attorney for Healthcare Services
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
Face Sheet Names
Admit and Discharge Record
Registration Record
Admission Summary Sheet
Interval Notes MUST Include
Information about the patient’s current complaint
any relevant changes in condition,
physical findings since last admission
First order required in all inpatient charts
-Filled out by physician who admitted the patient
Admission Order
Last required order in the chart unless patient leaves Against Medical Advice (AMA)
-Completed by the attending physician who discharged the patient
Discharge Order
Types of Progress Notes
Admission Note
Daily Notes
Integrated Progress Notes
Nursing Notes
Discharge Note
First note written once the patient is admitted to a specific unit
-Gives a brief overview of patient and current conditions
Admission Note
Progress notes are normally written daily by professionals but frequency can vary by patient condition
-Written by multiple disciplines (integrated)
Daily Progress Notes
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
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
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
When to Consider a Consultation
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
Admission Nursing Assessment
Care Plans
Progress Notes
Medication Records
Flow Charts
Transfer Records (Referral Form)
Nursing Documentation
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
Flow Charts-Vital signs are recorded
Every 2 hours
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
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
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
Not Part of the Medical Record
Incident Reports
Billing and Financial Information
Peer Review Documents
Any occurrence that is not consistent with the routine operation of the hospital or a situation that has risk management implications requires an
Incident Reports
Peer Review Committee meeting minutes are kept permanently and confidentially in medical staff or administrative offices
Utilization Review Worksheets
Peer Review Documents
Graphic Record
Vitals
Weight
Intake
Output
Special Orders
Do Not Resuscitate (DNR)
Use of seclusion or restraints
o All types must be signed and dated
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
The business record generated at or for a healthcare organization.
Legal EHR
Data about data
Metadata
Security Elements of a Legal EHR
Audit Trails
Metadata
Versioning
Alterations
How to authenticate a user
By something the user knows (password)
By something the user has (computer token)
By something the user provides (a written signature or fingerprint)
The access, use and prevention of information, data and records created or maintained in electronic media.
E-Discovery
The process to suspend normal destruction when there is a reasonable anticipation of litigation to prevent spoilage of evidence.
Legal Hold
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
Primary care person is the one who coordinates the health for a home care hospice patient (patient’s nurse)
Hospice
Put on some form of other storage medium
Inactive
No retention guidelines in Michigan, regulatory agencies is 5 years. May be stored off site in paper format.
Active File Storage
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)
Average length of stay in acute care hospital
30 days or less
Hospitals Can Be Classified By
Number of beds
Types of services provided
Types of patients serviced
For-profit or not-for-profit status
Type of ownership
Primary responsibility for setting direction of hospital
Hospital Board of Directors
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
State
Required to operate
Standards
Licensure
Conditions of Participation
Standards
Deemed status
Certification for Medicare Participation
An electronic record of health-related information on an individual within one health organization
Electronic medical record
An electronic record of health-related information on an individual across more than one healthcare organization
Electronic health record
American National Standards Institute (ANSI) accredited organization who provides standards for the exchange, integration, sharing, and retrieval of electronic health information
Health Level Seven (HL7)
Ability to exchange data among information systems
Interoperability
Nonrepudiation can be obtained through the use of
Digital signatures
Confirmation services
Timestamps
Scanned image of a “wet” signature; weak because someone can acquire a copy of the image and use it
Digitized signature
Cryptographic signature that authenticates the user
Digital signature
Application of password to an electronic document
Electronic signature
Buy the best system for the specific function, thus systems are coming from many vendors
Best of breed
Buy systems for hospital from a single vendor
Best of fit
Expensive and massive undertaking, but
May be best way to achieve desired results efficiently and effectively
Rip and replace
Who issues licenses for Michigan healthcare facilities?
The State
Which organization issues licenses for Michigan healthcare facilities?
Michigan Consumers & Industry Services, Bureau of Health Services
Does a facility have to be licensed?
It is mandatory to operate.
What must a facility be in compliance with to be licensed?
Must be in compliance with Michigan Rules and Minimum Standards for Hospitals
How often must a facility be reviewed for licensing?
Annually-usually completed at the same time as certification surveys
The approval of the state to build or expand health care facilities and services
Certificate of Need- State Issued
Granted to all healthcare facilities that are in substantial compliance with Federal Regulations governing each type of health care setting
Certification
Certification is granted by?
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
Conditions of Participation
Does a facility have to have Accreditation?
Voluntary participation by hospitals
Financial and legal incentives to attain accreditation
Accreditation is required for?
Required for reimbursement for certain patient groups including Medicare and Medicaid
Once an organization is found to be in substantial compliance with Joint Commission Standards accreditation may be awarded for up
3 years
Hospitals must undergo a full survey at least
Every 3 years
The Joint Commission will give organizations an opportunity to avoid dates per year.
10 dates per year
End of life care
Palliative Care
AOA Scoring
1. Full Compliance
2. Essential Compliance
3. Marginal Compliance
4. Non-Compliance
NA-Not Applicable
Individuals who receive acute-care services in a hospital are considered
Inpatients
Ambulatory surgery does not require
An overnight stay in a hospital
Primarily responsible for monitoring the daily operations of an entire health care organization
Chief executive officer
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
Has the responsibility of setting the overall direction of the hospital
Board of Directors
Primary focus of AHIMA
Promote/provide professional development of its members
Discrete data are entered into the EHR via
Templates
Macro
Point and Click
Voice Command
Web page that offers secure access to data
Portal
Interface is
Program to exchange data
Step by step approach to installing, testing, training and gaining adoption for an EHR is
Implementation Plan
Security of an EHR is afforded via
Access controls
Ensures accurate and timely data entry
Data Quality
An ideal EHR system is one that requires point of care charting
Supports clinical decision making
Types of Filing Systems
Straight numeric filing systems
Terminal-digit filing system
Middle-digit filing system
Alphanumeric Filing Systems
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