Health Data Content and Standards

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  1. The following are examples of 
    Registration data
    Demographic data
    identifier number
    Advance directives
    patient rights
    Birth and death certs
    Administrative and demographic data
  2. The flowing documents are examples of:
    Medical History
    Physical Examination
    Diagnostic and therapeutic orders
    progress notes
    nursing documentation
    ancillary services
    surgical services
    discharge summary 
    records form other facillities
    Clinical Data
  3. The following are examples of :
    Obstetric patient
    Emergency room patient
    outpatient records
    behavioral health care
    hospice care
    rehabilitation services
    long-term care
    Specialized content
  4. 4 formats of the paper-based record
    • source-orientated health records
    • Problem-orientated health records
    • integrated health records
    • universal chart order
  5. What are some incomplete record controls
    • Quantitative analysis
    • -criteria for adequacy of documentation
    • -record completion policies and procedures
    • Qualitative analysis
    • -role of HIM personnel
    • -role of medical staff
    • -assurance that documentation in the record supports the diagnosis and reflects the progress, clinical findings, and discharge status
  6. User requirements of an Electronic health record:
    • Record content
    • Data access
    • data capture/collection/retrieval
    • record format
    • system performance
    • linkages
    • intelligence (clinical guidelines, protocols, and pathways)
    • Reporting capabilities
    • control and access
    • security controls
    • reliability
    • Confidentiality and security
    • access controls and audit controls
    • building blocks
  7. Methods of Data capture/collection/retrieval
    • screen density
    • size of device
    • search capability
    • content positioning and navigation support
    • consistency of design
    • graphics
    • colors and icons
    • structure text
    • template-based entry
    • natural processing language
  8. Name security controls
    • agents
    • targets
    • events
  9. Reliability controls
    • errors
    • crashes
    • performance problems
  10. Confidentiality and security
    • privacy/confidentiality
    • security
  11. examples of building blocks
    • architecture
    • internet
    • vocabularies
  12. What are Healthcare Information processing standards
    • ANSI - american national standard insitute
    • ASCX3, ASCX12, ASTM committee E31, HL-7, IEEE P107
  13. Main functions of Joint Commission
    • Accreditation Standards
    • Survey Process
    • Shared visions- New pathways
    • Management of information standards
    • National patient safety goals
    • ORYX-Core Measures
  14. Joint Commission - Accreditation standards
    • Chapters
    • standards
    • rationale
    • Elements of performance (scoring and categories of EPs)
  15. Survey Process
    • Survey Teams
    • Documentation review
    • exit conference
  16. Joint Commission - shared vision - new pathways
    • Survey process component
    • -periodic performance review
    • -priority focus process-clinical/service groups; priority focus areas
    • Tracer methodology
Card Set:
Health Data Content and Standards
2013-05-29 17:11:20
RHIT Health Data Content Standards

RHIT Health Data Content and Standards
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