Health Data Content and Standards

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Author:
Anonymous
ID:
221576
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Health Data Content and Standards
Updated:
2013-05-29 13:11:20
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RHIT Health Data Content Standards
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RHIT Health Data Content and Standards
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  1. The following are examples of 
    Registration data
    Demographic data
    identifier number
    Consents
    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
    consultations
    nursing documentation
    ancillary services
    surgical services
    discharge summary 
    records form other facillities
    Clinical Data
  3. The following are examples of :
    Obstetric patient
    newborn
    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
    • SNOWMED-CT
  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

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