HITT 1401-Lab Final

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HITT 1401-Lab Final
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Lab Exam #1&2
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  1. Introduction to Paper and
    Electronic Health Records
    HITT 1401 -Lab Exam #1
    • Introduction to Paper and
    • Electronic Health Records
    • HITT 1401
  2. 1a. Describe how Health Record’s serve as resource documents
    • – Clinical decisions
    • – Administrative decisions
    • – Data collections
  3. 1b. Describe how Health Record’s serve as legal documents
    They must: – Identify the patient – Support the diagnosis or reason for encounter – Justify the treatment rendered – Accurately document the results of treatment
  4. 3. Difference between Primary data and medical record
    • Primary - Medical record
    • Secondary - health data base
  5. 2. Who provides the information in the
    medical record?
    • Facility
    • Medical staff
    • Nursing or Alliead Health professionals
    • HIM department
  6. 4a. Describe the ownership of the media on which health information is stored.
    Hosptila/facilit/organization owns the media
  7. 4b. Describe the ownership of the information contained in the medical record.
    Patinet owns the information
  8. 6. Describe general health record requirements regarding:
    A. timeliness
    B. legibility of data
    C. meaning and usefulness
    D. completion of the medical record itself
    A. timeliness - immediately

    b. completion of the medical record itself

    c. legibility – Reports should be dictated and transcribed when feasible and appropriate

    d. meaning and usefulness– The information in the medical record must be • Clear • Concise • Relevant

    e. Legality of data – Information must be documented, authenticated, corrected and stored in a manner that meets legal and accreditation requirements
    (this multiple choice question has been scrambled)
  9. 7. Define "authentication"
    Confirmation of truth and proof
  10. 8. Describe acceptable methods, for correcting errors in an electronic health record
    – Errors must be corrected in compliance with JC, AOA and CMS requirements
  11. 9. Describe the basic policies that should apply to the use of abbreviations and symbols in the health record.
    • – Must be approved by the medical staff
    • – Must have a legend available to the health care provider at all times
    • – Each abbreviation and symbol must have only one meaning
    • – Facilities must comply with JC’s “Do Not Use” List
  12. 10. Explain why "DO NOT USE" abbreviation lost was adopted by the Institutue
    Accredication required
  13. 11. Regarding electronic  health records, explain the implications of the following:
    a. President George W Bush Executive Order creating the Office of the National Coordinator for Health Informaiton Technology
    – President George W. Bush created the Office of the National Coordinator for Health Information Technology (ONCHIT) • Outlined a strategic national agenda for health information exchange (HIE) • Laid foundations for RHIOs
  14. 11. Regarding electronic  health records, explain the implications of the following:
    b. ePrescribing Inccentives
    Federal funding provided for physicians' clinics to submit Rx electronically, or not get paid.
  15. 12.Define:
    a. AHRQ
    • July 2003
    • – DHHS’s Agency for Health Care Research and Quality (AHRQ)
    • • Requested the IOM and HL7 design a functional EHR model and standard
    • • Identified gaps in knowledge re use of EHRs
    • Recommended more research on impact of EHRs
    • Encouraged collaboration
  16. 12.Define:
    b. EHR
    • – IOM identified three key criteria for an EHR
    • • Must be able to integrate data from multiple sources
    • • Must be able to capture data at the point of care
    • • Must support caregiver decision-making
  17. 12.Define:
    c. HIE
    Health information exchange (HIE) is the mobilization of healthcare information electronically across organizations within a region, community or hospital system.
  18. 12.Define:
    d. HI7
    Health Level Seven (HL7), is a non-profit organization involved in the development of international healthcare informatics interoperability standards.
  19. 12.Define:
    e. IOM
    The Institute of Medicine (IOM) is a not-for-profit, non-governmental American organization founded in 1970, under the congressional charter of the National Academy of Sciences.
  20. 12.Define:
    f. RHIO
    A Regional Health Information Organization (RHIO, pronounced rio), also called a Health Information Exchange Organization, is a multistakeholder organization created to facilitate health information exchange HIE) – the transfer of healthcare information electronically across organizations – among stakeholders of that region's healthcare system.
  21. 13. Describe and apply meaningful use criteria, as they apply to the implementation of EHR.
    The use of EHR and allows providers to gain incetive payments by meeting certain criteria
  22. Health Record Forms and
    Reports
    Health Record Forms and Reports
  23. 1. Define
    a. provisional diagnosis
    •  Provisional diagnosis
    • • Impression • Admitting dx • Tentative dx
    •  Physician’s medical opinion prior to conducting tests
    •  Must be recorded on the H&P
  24. 1. Define
    b. differential diagnosis
    •  Differential diagnosis
    • • Several provisional diagnoses which the physician considers possible
    •  May be stated as
    • • “Rule Out”
    • • R/O:
    •  May be recorded on the H&P
    •  NEVER on the D/C Summary
  25. 1. Define
    c. principal diagnosis
    •  Principal dx
    • • The condition established after study to be the main reason for the admission of the patient to the facility
    •  Must be recorded on the Discharge Summary
  26. 1. Define
    d. secondary diagnosis (es)
    •  Secondary diagnoses
    • • Additional complications or conditions which the patient has a history of or which developed during the hospitalization
    •  Must be recorded on the Discharge Summary
    •  Limited number can be submitted to insurance companies for billing
    • • Will learn sequencing rules in Coding classes
  27. 1. Define
    e. final diagnosis
    •  Final Diagnosis
    • • Principal diagnosis plus those secondary diagnoses affecting the hospitalization
    •  Must be stated in current medical terminology
    •  Cannot include abbreviations
    •  Must be recorded on the Discharge Summary
  28. 1. Define 
    f. preoperative diagnosis
    • Preoperative Diagnosis
    • • Statement of the reason for surgery or expected findings
    • • Must be recorded by the surgeon prior to surgery
    • • Must be restated on Operative Report after surgery
  29. 1. Define 
    g. postoperative diagnosis
    •  Postoperative Diagnosis
    • • States the clinical findings as they are known immediately after surgery
    • • Must be recorded by surgeon immediately after surgery
    • • Must be recorded on Operative Report
  30. 1. Define 
    h. pathological diagnosis
    •  Pathological diagnosis
    • • Description of the cellular characteristics of tissue removed during surgery
    • • Includes • Gross description • Microscopic description • Must be recorded by the pathologist • Must be recorded on Pathology Report
  31. 1. Define 
    i. provisional anatomical protocol
    • Provisional anatomical dx
    • • Initial determination of cause of death based on available autopsy results
    • • Must be recorded within 3 days of death
  32. 1. Define
    j. complete anatomical protocol
    • Complete anatomical protocol
    • • Final determination of the cause of death based on completed tissue studies
    • • Must be recorded within 60 days of death
  33. 2. Describe the general purpose and required content items of each of the forms and reports included in these sections of this packet:
    a. Medical Forms and Reports
  34. 2. Describe the general purpose and required content items of each of the forms and reports included in these sections of this packet:
    b. Nursing Forms and Reports
    • Requirements
    • • Admission note (may be recorded on separate form called nursing admission assessment or nursing admission evaluation)
    • • Each entry must be authenticated by nurse making the entry

    •  Includes
    • • Date and time of administration
    • • Name of drug
    • • Dose
    • • Route of delivery
    • • Intentional omission of med
    • • Authentication of person administering the medication
  35. 2. Describe the general purpose and required content items of each of the forms and reports included in these sections of this packet:
    c. Ancillary Forms and Reports
    • Allied health professionals must document treatments rendered and results of treatment 
    • Must be authenticated by professional who rendered the treatment
  36. 2. Describe the general purpose and required content items of each of the forms and reports
    included in these sections of this packet: 
    d. Obstetric Records
    • Must be completed by nursing personnel as frequently as patient’s condition / hospital policies require
    •  Each entry must be authenticated
  37. 2. Describe the general purpose and required content items of each of the forms and reports included in these sections of this packet:
    e. Newborn Records
    • Neonate must be examined by physician
    • • Within 12 hours of birth
    • • At least every 3 days thereafter
    • • Within 24 hours prior to discharge
    • • Must be authenticated by physician making the entries
  38. 3. Identify the items to be included in the History and Physical Exam.
    • History includes
    • • Chief complaint
    • • Present illness
    • • Past medical history
    • • Personal history
    • • Family history
    • • Review of systems
    •  Physical exam includes
    • • Record of physician’s findings at time of exam
  39. 4. State the Joint Commission and AOA completion requirements (time frames, who must authenticate) for the H&P.
    • Completion requirements
    • • Must be completed and filed within 24 hours of adm (JC)
    • • Must be completed within 24 hours of adm and filed on chart within 48 hrs of adm (AOA)
    • • Must be documented on the health record prior to surgery
    • • Must be authenticated by the admitting physician
    • • Does not have to be typed. Legible H&P on admission progress note is acceptable
  40. 5. State the qualifications for using an Interval History and Physical Exam.
    • • It must have been recorded within 30 days prior to admission AND
    • • Patient must be readmitted with the same condition AND
    • • All changes in patient’s
    • condition are documented at the time of admission
    • • Must be signed/ authenticated by admitting physician
  41. 6. Name and define the four types of physicians’ orders, and be able to identify each.
    • 1.Written orders
    • • Doctor writes, inputs
    • 2.Verbal orders
    • • Doctor gives the order verbally in person or over telephone

    • 3.Standing orders (routine orders)
    • • A set of orders the physician requires for
    • all of his/her patients admitted with a
    • particular condition

    • 4.Automatic stop orders
    • • For narcotics, some antibiotics
    • • Medication will automatically stop on
    • a specified date unless physician renews the order in writing
  42. 7. Describe the completion requirements (Joint Commission and AOA) for physicians’ orders.
    • Must be dated, timed and signed by
    • physician giving the order
    • • Standing orders must be made patientspecific
    • • Must include a discharge order
  43. 8. State special precautions to be taken when using standing orders and verbal orders.
    Examine patient hx, conditions or symptoms
  44. 9. Describe the completion requirements (Joint Commission and AOA) for physicians’
    progress notes.
    • Must be written as frequently as required by patient’s condition and MS bylaws
    • • Must be dated, timed and signed by physician making the entry
  45. 10. Describe the items that should be included and the completion requirements for the
    Discharge Summary.
    • Recaps patient’s course in the hospital
    •  Should include
    • • Reason for hosp.
    • • Significant findings
    • • Procedures / response
    • • Therapies / response
    • • Cond at discharge
    • • D/C instructions

    •  Requirements
    • • All relevant diagnoses must be recorded in acceptable medical terminology
    • • Should be written or dictated by attending physician within 30 days of discharge
    • • Must be authenticated by physician who
    • wrote/dictated the rept
  46. 11. Describe the three situations in which a Short Stay Record may be used instead of an H&P and Discharge Summary, and state who must authenticate this form.
    • Qualifications for use
    • • Minor, uncomplicated conditions OR
    • • Uncomplicated obstetrical deliveries
    • OR
    • • Healthy newborns discharged within 48 hrs
  47. 12. Describe the types of conditions which warrant a medical consultation, and identify who is responsible for requesting the consultation and authenticating the report.
    • Must be requested by the attending
    • physician
    •  Requirements
    • • Consultant must
    • • Review patient’s health record
    • • Examine the patient
    • • Document findings on a Consultation
    • Report
    • • Authenticate the report
  48. 13. Explain what is meant by the term, “Operative Set” and identify the reports that are normally included in the operative set, along with the completion requirements for each.
    • Also called Surgical Nurses’ Report Includes
    • • assessment of required items
    • • Documentation of preop procedures
    • • Document of post-op procedures
    • 
    • Requirements
    • • Must be authenticated by nurse in charge of the operating room or another appointed operating room nurse
  49. 14. State who is responsible for authenticating each of the following reports:
    A. imaging reports
    B. electrocardiogram reports
    C. electroencephalogram reports
    A. imaging reports -Authenticated by radiologist

    b. electrocardiogram reports - Must be authenticated by cardiologist ordering the exam

    c. electroencephalogram reports - Must be authenticated by neurosurgeon or neurologist ordering the exam
    (this multiple choice question has been scrambled)
  50. 15. State the major items that must be documented in a transfusion record, and state who is responsible for authenticating that report.
    Physician must order blood and blood products

    •  Requirements
    • • Donor ID #, blood type, Rh factor
    • • Recipient name, ID #, blood type, Rh factor
    • • Date and time of transfusion and products administered
    • • Patient’s condition before, during and after transfusion
    • • Transfusion reactions
    • • Released units
    • • Authenticated by person administering transfusion
  51. 16. List the three major sections of the Obstetric Record and describe the elements that must
    be included in each.
    • 1. Antepartum Record (about mother)
    •  Health history
    •  Family history
    •  Social history
    •  Physical exam

    • 2. Labor and Delivery Record
    •  Updated history
    •  Ongoing assessment
    •  Delivery data
    •  Attendance of neonatal staff if delivery is premature or complicated
    •  Delivery data, cont’d
    •  Must be signed by physician or nurse

    • 3. Postpartum Record
    •  Condition of mother after delivery
    •  Must be completed by nursing personnel as frequently as patient’s condition / hospital policies require
    •  Each entry must be authenticated
  52. review17. List the four major sections of the Newborn Record and describe the elements that must be included in each.
    • 1. Birth history
    • • Maternal history
    • • Labor and delivery information (length of labor, method of delivery, APGAR scores, etc.
    • • Prematurity
    • • Abnormalities
    • • Problems
    • • Must be completed and authenticated by
    • nurses or physician

    • 2. Newborn Identification
    • • Identification bands for mother, father and neonate
    • • Name of mother /
    • • Neonate’s gender / last name
    • • Time of birth
    • • ID number
    • • Footprinting, fingerprinting, blood
    • typing as required
    • • Nurse in charge of delivery room is usually responsible for the
    • identification process
    • • Must sign appropriate reports along

    • 3. Newborn physical exam and tests
    • • History of delivery and birth
    • • Detailed description of neonate’s appearance
    • • Orders for / results of necessary tests
    • • Neonate must be examined by physician
    • • Within 12 hours of birth
    • • At least every 3 days thereafter
    • • Within 24 hours prior to discharge
    • • Must be authenticated by physician

    • 4. Newborn progress notes
    • • Vital signs
    • • Color
    • • Respirations
    • • Weight (daily)
    • • Feeding
    • • Presence of irritability
    • • Observations must be made and recorded at least every 8 hours until discharge (more frequently for premature and sick
    • infants)
    • • Entries must be authenticated by the
    • nurse making the observations
  53. Numbering and Filing Systems
    Numbering and Filing Systems
  54. 1. Difference between numbering and filling system
    Numbering - to assign MR# to patients

    Filing system - to file charts, regardless of numbering system
  55. 2.       Name and describe the three types of numbering systems that may be used in       assigning medical record numbers to patients.
    • UNIT NUMBERING SYSTEM
    • Patient receives the same medical record number on every admission
    • Objective: To have all of the patient’s previous medical records located in  the same place in the file
    • 
    • SERIAL NUMBERING SYSTEM
    • Patient receives a different M R # on each admission
    • Objective: To issue each patient a new medical record number each time he or she is admitted

    •  SERIAL-UNIT
    • Pt receives new number each time; each one is pulled forward and filed with subsequent chart
    • Objective: To assign a new number each time, but to have all of the patient’s previous charts filed in the same location.
  56. 3.       Discuss advantages and disadvantages of each numbering system.
  57. 4.       Describe these alternatives to the unit numbering system, and explain appropriate applications: 
    a.       Social Security Numbering System 
    b.       Family Numbering System
    a.       Social Security Numbering System -Patient’s SS# is used as his/her MR# A pseudo-number (9-digit #) is assigned for patients who do not have SS#

    • b.       Family Numbering System -
    • Family number is assigned 12345
    • Head of household = 01 01-12345
    • Spouse = 02 02-12345
    • Oldest child = 03 03-12345
    • Next child = 04 04-12345 etc.
    • Recommended only in limited applications
  58. 5.       Explain appropriate use of a pseudo-number.
    A pseudo-number (9-digit #) is assigned for patients who do not have SS#
  59. 6.       Give examples of appropriate HIM applications of the alphabetic filing system.
    • Applications
    •  Master Patient Index
    •  Medical office with less than 5,000 records, minimal computerization and stable population
  60. 7.       Alphabetize names, applying alphabetic filing rules.
    • File by last name first, followed by first name, then middle name or initial
    • If there is more than one person with identical last, first and middle names, use the birth date, filing the oldest patient first
  61. 8. Describe advantages and disadvantages of 
    a.       straight numeric filing method
    b.       terminal digit order filing method
    a.       straight numeric filing method -Records are filed in exact chronological order

    b.       terminal digit order filing method - A numeric filing system which reorders the manner in which the number is read and filed
  62. 9.       In terminal digit (TDO)filing, identify the
              a.       primary digits
              b.       middle digits
              c.       tertiary digits
    • a.       primary digits -last pair of digits     
    • b.       middle digits - middle pair of digits
    • c.       tertiary digits - first pair of digits
  63. 10.     When using the TDO filing method, explain why the file room must be divided into 100 sections.
  64. 11.     File (and/or arrange) medical record numbers in straight numeric order.
  65. 13. In assigning medical record numbers, explain why careful attention must be paid to avoid assigning duplicate numbers.
    To avoid patient informaiton mix up
  66. 14. When filing medical records, explain why careful attention must be paid to avoid misfiles.
    To locate patient information records in timely manner
  67. 15.     Explain how medical record numbers are assigned in 
    a.       a paper-based medical record system 
    b.       an electronic medical record system
    • a.       a paper-based medical record system - admissions staff assigns number using a Number Log
    • Number Log chronological register of assigned / available numbers maintained by either the HIM department or the Admissions Department
    • b.       an electronic medical record system - system is programmed to assign the number
  68. 16.     Describe the purpose of the Number Log.
    Number Log chronological register of assigned / available numbers maintained by either the HIM department or the Admissions Department
  69. HEALTH RECORD ANALYSIS
    HEALTH RECORD ANALYSIS
  70. 1a.     quantitative analysis
    Assuring that the record meets all documentation requirements
  71. 1 b.     qualitative analysis
    Checking for errors and inconsistencies in documentation
  72. 1c.      legal analysis
    Verifying that the record meets all legal requirements
  73. 1d.     statistical analysis
    Abstracting / compiling statistical data for tracking and trending purposes
  74. 1e.     clinical pertinence
    • Reviews of charts performed in addition to quantitative analysis to determine whether specific required or forbidden elements are present
    • – These reviews are not performed for completion purposes, but rather to determine whether standards/policies are being followed
    • – CP items are selected by the facility
  75. 1f.      concurrent analysis
    Any review performed while the patient remains hospitalized
  76. 1g.     retrospective analysis
    Any review performed after the patient was discharged from the facility
  77. 1h.     equal access
    Joint Commission requirement: In order to meet the 30-day completion requirement, the facility should provide equal access to incomplete records.
  78. 1i.      incomplete medical record
    A medical record with specific deficiencies that can be completed by a health care provider
  79. 1j.      delinquent medical record
    An incomplete medical record that has not been completed within the time specified in the medical staff bylaws
  80. 2.  Describe the steps involved in quantitative analysis.
    • Assemble record in order (paper records)
    • • Analyze for deficiencies
    • • Indicate deficiencies for each doctor on a
    • deficiency report; notify physicians
    • • File the record in the incomplete file (paper) so that it is available for doctors to complete, on request
    • • Re-analyze until all deficiencies are corrected
    • • Perform a final recheck
    • • File in permanent file (paper) or send
  81. 3.  Describe the steps involved in deficiency notification (paper and electronic.)
    • – Send email notice to physician regarding items to be completed
    • – Physician accesses charts electronically from the hospital, office or home
    • – Physician dictates reports, signs entries electronically
    • – Do recheck, final analysis
  82. 4.  Explain advantages of concurrent quantitative analysis, and describe methods for performing this process.
  83. 5.  Describe the steps that should be taken to manage incomplete / delinquent charts.
    • HIM Department – perform incomplete and delinquent chart counts weekly
    • • Physicians should receive a warning if they have charts reaching “delinquent status”
    • • All physicians with delinquent charts should be placed on the hospital’s “Delinquent List” (usually referred to as “Suspension list”)
    • • Admissions Department should be required to check the physician’s status on the Suspension List prior to admitting patients
    • • Requires absolute administrative support
  84. 6.     Discuss reasons for managing incomplete / delinquent chart rates.
    Valid and current health information records
  85. 7.  Discuss acceptable strategies for getting doctors to complete their records.
    Admissions Department should be required to check the physician’s status on the Suspension List prior to admitting patients
  86. 8.     Perform quantitative analysis of medical records.
    • All necessary forms and  reports
    • Must be signed (and dated) as required by accreditation standards
  87. 9.     When given the necessary data, compute the incomplete chart rate.
    Calculating Incomplete Chart Rates

    • # of incomplete charts / # of discharges [or other patient care episodes] during the required completion period
  88. 10. When given the necessary data, compute the delinquent chart rate.
    Calculating Delinquent Chart Rate

    • # of delinquent records / average # of discharges during the stated time period
  89. 11. Identify whether the facility is over the allowable number of delinquent charts according to Joint Commission standards.
    • Joint Commission Requirements
    • • The number of delinquent records should not exceed 50% of the average number of discharged patients per quarter over the previous 12 months

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