Chpt 8 test.txt

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Chpt 8 test.txt
2012-11-04 17:27:44
Health Record

Chpt 8/HIT
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  1. what dr records and is put into written word-
  2. written-
  3. thought/comprehended-
  4. HIM dept's typically manages the following support services-
    • record processing
    • monitoring of record completion
    • transcription
    • release of patient info
    • clinical coding
  5. HIM dept may manage the following functions:
    • research & statistics
    • cancer and/or trama registries
    • birth certificate completion
  6. what works & doesn't; what needs to be changed-
    work flow analysis
  7. EDMS-
    electronic document management systems
  8. part of EHR; documents to help manage-
  9. MPI-
    master patient index
  10. primary guide to locating pertinent demographic data about the patient & his/her health record #; permanent record of every patient ever seen in the healthcare entity-
  11. Basic info usually included in the MPI-
    • patients last, first & middle names
    • patients health record #
    • patients date of birth
    • patients gender
    • dates of encounter (admission & discharge dates are usually maintained for inpatients)
  12. patients registration system, also known as the registration, admission, discharge, transfer system-
  13. assignment of a new patient medical record # to an individual that has an existing medical record #-
    duplicate medical record #
  14. a patient is assigned another patients medical record #-
  15. when more than 1 medical record # exists for the same person within an enterprise at different facilities or in different databases-
  16. 2 different MPI's & makes a bigger/huge system-
  17. HIE-
    health information exchange
  18. frequently used to describe both the sharing of health infomation electronically among 2 or more entities & also an organization that provides service to accomplish this info exchange-
  19. key date element in the MPI-
    health record #
  20. patient receives a unique numerical identifier for each encounter or admission to a healthcare facility/#'s are issued in a series-
    serial numbering system
  21. most commonly used; the patient receives a unique health record # at time of the first encounter and the same # is used every visit-
    unit numbering system
  22. numbers are assigned in a serial manner, but during each new patient encounter, the previous health records are brought forward & filed under the last assigned health record #-
    serial-unit numbering system
  23. patient's last name is used as the 1st source of identification & his/her first name & middle initial provide further id-
    alphabetic identification and filing system
  24. the method most commonly used as the unique identifier in the EHR environment-
    unit numbering
  25. records are filed by health record #; is an indirect filing system; an index or authority file needs to be consulted before the user can identify a record assoc. w/a specific patient ie: master patient index-
    numeric filing system
  26. records are assigned consecutively in ascending (smaller to larger) numberic order; the # assigned to each file is the health record #
    straight numeric filing system
  27. considered most efficient; the last digit or group of last digits is the primary unit used for filing, followed by the middle unit & the last unit of #'s; (file#, shelf, row)-
    terminal digit filing system
  28. the primary unit is the middle unit, the secondary unit is the 1st unit to the left, followed by the last digits (shelf, row, file#)-
    middle digit filing system
  29. uses a combination of alpha letters & #'s for identification purposes; the 1st 2 letters of the patient's last name are followed by a unique numeric identifier; this system is appriopriate for small organizations-
    alphanumeric filing system
  30. individual patient encounters are filed by the same unique identifier & in the same location; the unique identifier can be alphabetic, alpha-numeric or numeric-
    centralized unit filing system
  31. converts paper documents to archive-stored images by taking a picture of the original document & storing it as a very small negative-
    milcrofilming process
  32. negative of health records; have mulitple #'s (serial # unit) on multiple rolls of films-
    roll microfilm
  33. microfilm cut & put into folders; put together for 1 person; alphabetic, straight, numerical, terminal digit used-
    jacket microfilm
  34. everything is departmentalized; labs, radiology, etc are together, copied & put on microfilm; never remove3d from dept unless record is old-
  35. request from a clinical or other area in the organization to charge out a specific health record; may be in paper or electronic form; the form usually includes patient's name, health record #, date of request, date & time needed, name of requestor & location for delivery-
  36. incomplete record that is not rectified within a specific # of days as indicated in the medical staff rules & regulations-
    deliquent record
  37. review for deficiencies by the HIM dept is called-
    quantitative analysis
  38. review occurs concurrently with the patient's stay in the hospital-
    concurrent review
  39. process of extracting data from the health record & entering them into a computer database-
  40. indexes, diagnoses and operative codes that are used as guides or pointers to the health records of patients who have had a specific disease or operation; are essential for locating health records to conduct quality improvement & research studies, as well as monitoring quality of care-
    disease and operation index
  41. index that is a guide to identifying medical cases associated with a specific physician-
    physician index
  42. a non-profit organization that offers an accreditation program for hospitals and other healthcare orgainzations based on pre-established accreditation standards=
    Joint commission
  43. Other entities beside TJC that have established documentation standards-
    • Medicare conditions of participation
    • National Committee for Quality Assurance (NCQA)
    • American Accreditation Health Care Commission/Utilization Review Accreditation Comm
    • American osteopathic Association (AOA)
    • Commission on Acdcreditation of Rehalbilitation Facilities (CARF)
    • Health Accreditation Program of the National League of Nursing
    • College of American Pathologists (CAP)
    • American Association of Blood Banks (AABB)
    • American College of Surgeons (ACS)
    • Accreditation Association for Ambulatory Health Care (AAAHC)
    • American NMedical Accreditation Program (AMAP)
  44. Healthcare organizations accredited by TJC are also deemed to be in compliance with the Medicare Conditions of Participation-
    deemed status
  45. a plan that converts the organizations goals and objectives into targets for revenue and spending; its a planning tool as well as an evaluation tool-
  46. a predication of how much money an organization's activities will generate during a certain period-
    revenue budget
  47. a predication of how much expense an organization is going to generate; includes such things as employee salaries and supplies-
    expense budget
  48. a projection or plan of what the organization intends to spend on long-lived assets such as a piece of equipment-
    capital budget
  49. the anticpated flow of cash into and out of the organization (donations, petty cash)-
    cash budget
  50. the process in which digital text stored on computer can be read by software and automatically coded-
    Natural Language Processing (NLP)
  51. would have enterprise or facility wide responsibiltiy for HIM; includes working w/the chief information executive & system users to advance systems, methods, & application support & to imporve data quality, access, privacy, security & usability-
    health information manager/Vision 2016
  52. would perform data management functions in a variety of application areas, including clinical coding, outcomes management, specialty registries and research databases-
    clincial data specialist/Vision 2016
  53. would perform new service roles that help consumers manage their personal health info, including personal health history management, ROI, managed care services & information resources-
    patient information coordinator/Vision 2016
  54. would perform functions involving formalized continuous quality improvement for data integrity throughout the enterprise, beginninbg w/data dictionary & policy development & including quality monitoring & audits-
    data quality manager/Vision 2016
  55. would be responsible for the next generation of records & data management using media such as CPR, the data repository & electronic warehousing for meeting current & future care needs across the continuum, providing access to the needed information & ensuring long-term integrity and access-
    date resource administrator/Vision 2016
  56. would support senior management w/info for decision making & strategy development using a variety of analytical tools & databases; the position would work w/product & policy organizations on high-level analysis projects such as clinical trials & outcomes research-
    research and support analysis/Vision 2016
  57. manage the security of all electronically maintained info, including the promulgation of security requirements, policies and privilege systems and performance audits-
    security officer
  58. CAC-
    computer assisted coding