Primary Data Source
Patient specific/identifiable data
Related to a specific individual
ex. The Health Record
Secondary Data Source
Information on groups of people or patients without identifying any particular patient individually.
Also called "Aggregate Data"
Compiled from multiple health records
Ex. Data taken from the health record and entered into registries and databases are considered secondary data.
Checking for the presence or absence of necessary reports or signatures. Ex. progress notes, orders
Completeness and Accuracy
Making sure a document is there and authenticated
Focuses on physician documentation
Ex. Checking documentation consistency, such as contraindications in entries,progress note dated prior to admission etc
Quality of records
Does documentation reflect the quality of patient care provided
Written accounts of unusual events that have an adverse effect on a patient, employee, or facility visitor.
Never filed in patient health record.
Used by risk management and or attorney to investigate incidents that have the potential to become claims against the organization or individual provider.
res ipsa loquitor
"the thing speaks for itself"
The injury would not ordinarily occur without someones negligence Ex. Surgical instrument left in patient after surgery
Process of comparing an organization to a standard, a peer group, or other organization.
Ex. A hospital may want to compare its ALOS (average length of stay) with the ALOS for all hospitals nationwide.
Continuum Of Care
Various types of healthcare services provided in diverse settings from basic primary care to complex tertiary settings.
Services provided by physicians working in private offices, group practices, private clinics or community based clinics.
Ex Family practice, pediatrics
Ex of primary care services: preventative,routine screening,physical exams
The provision of highly specialized and advanced diagnostic and therapeutic services in inpatient hospital settings.
National Practitioner Data Bank
Maintains information on medical malpractices claims against physicians
Hospital Governing Board
Establishes medical staff policies regarding qualification criteria and process
Medical Staff executive committee
Reviews each practitioners applications and submits recommendations to governing board
Healthcare Integrity and Protection Data Bank
Maintains information on legal actions taken against licensed providers
data related to the patients medical status and treatment
Medical record is the primary source of clinical data
numbers, characters, or symbols stored, processed and displayed are exact and conform to known standards (correctness of data)
Ex. ICD-9CM code 250 (this code is not valid as it needs additional digits)
data that is the same no matter who collected it or how many times it is collected
Ex. reliable data is consistent when entered into 2 or more databases
All required data points are present
Ex. birthdate 1/31, this is not complete because the yesr is missing
the period of time between recording or producing the data element and making the information available to users is short.
data must be relevant and understandable
Ex. the abbrev LOC appeared in a progress note, does it mean "laxitive of choice" or "loss of consciousness"
The condition established after study to be chiefly responsible for admission of the patient to the hospital
Explains the reason the patient was admitted to the hospital
All conditions that coexist at the time of admission, that develop subsequently, or that affect the treatment received and/or length of stay.
Include comorbidities and complications
Any condition that coexists during the relevant episode of car and EFFECTS THE TREATMENT PROVIDED TO THE PATIENT
(what patient comes in the door with)
pre-exisiting condition that will affect treatment or increase the patients length of stay
Any condition that arises during the relevant episode of care and EFFECTS THE TREATMENT PROVIDED TO THE PATIENT
Ex. post-op complications, injuries that arise during the stay
Arises AFTER the patient s admission to the hospital
A procedure that was performed for definitive treatment rather than one performed for diagnostic or exploratory purposes, or was necessary to take care of a complication.
If you have 2 procedures that appear to be principle then the one most related to the......
principle diagnosis should be selected as the principle procedure
What the physician suspects is wrong with the patient
"tentative or provisional dx"
Juvenile Onset Diabetes
Type 1 Diabetes
Develops due to absence of insulin production (insulinopenia)
Not determined by age
Requires an injection of insulin to maintain normal glucose levels
Commonly Used Insulins
Adult On set Diabetes
Type 2 Diabetes
Formerly known as NIDDM (non insulin dependent diabetes mellitus)
Insulin Requiring Diabetes
Patient is not dependent on insulin to live
Prone to develop dehydration
Impaired Glucose Tolerence
Dx given to people who have blood sugar levels higher than normal but not enough to be given the dx of diabetes
Review Of Systems
Physician asks patient a series of questions about how they feel.
Usually organized by body system
The physician does not touch the patient during ROS
Timing of H&P
Must be documented within 24hrs of admission
Must be documented before surgery
Can be documented no more than 7 days prior to admission
If pt is readmitted within 30 days for the same condition the physician may use an "interval note"
Usually by telephone
According to Medicare Conditions Of Participation state verbal order should be authenticated within 48 hrs
Written at time physician decides patient is ready to go home or be transferred to another facility
Purpose of Uniform Healthcare Data Sets
Ensure data collection for every patient is consistent
Enables comparison of health care data on a national level for analysis
Info about pt current complaint
Any relevant changes in condition
Physical Findings since last admission
Chronological record of the clinical observations of the pt condition and response to treatment during the hospital stay
Supports medical necessity
Written every 1 to 2 days
The more often the notes are written the better
Describe a specific procedure step-by-step
Kept as permanent part of the health record
Ongoing review of medical care to ensure the necessity and effectiveness of the services being provided to the patient
Charting By Exception
Document only abnormal/unusual findings, treatment rendered or patient response
Clinical Practice Guidelines
Guidelines which support and standardize clinical decision making for specific medical conditions
A multidisciplinary tool for organizing the diagnostic and therapeutic services to be provided to a patient
A discharge note may be substituted for a discharge summary when.........
hospitalization < 48hrs for an uncomplicated stay
uncomplicated delivery of an infant (moms record)
normal newborn infant (baby's record)
Autopsy Report Timeliness
Provisional Autopsy Record- within 3 days of autopsy
Final Autopsy Record- within 60 days after completion
Emergency Medical Treatment and Active Labor Act
Prohibits the transferring of uninsured patients to public hospitals to avoid treating them
restores pt ability to perform daily activities of living
(self care activities)
restores pt ability to enhance independent living skills through recreational opportunities
Source Oriented Health Records
Documents grouped together according to department they originated, then arranged in chronological (or reverse Chronological) order
Listing of patients past and present social,psychological, and medical problems.
Each problem indexed with a unique number
Reports/documentation reference the # of the problem they address
4 components of a problem-oriented health record
Database (contains CC,present illness,social/med hx,physical exam,test results)
Initial Care Plan
Format of progress notes
Subjective (what patient tells Dr)
Objective (what Dr observes)
Medicare Conditions Of Participation
Includes standards for health record content,confidentiality, and retention
Published under the Code Of Federal Regulations (CFR-42)
A daily legal newspaper, which publishes final changes/updates to the Code Of Federal Regulations
If a healthcare organization is accredited by Joint Commission or AOA they are automatically eligible for Medicare/Medicaid reimbursement
Timeliness of Delinquent Records according to Joint Commission......
records are considered delinquent if not completed within 30 days after discharge
Stage I Decubitus Ulcer
Nonblanchable erythema of intact skin the heralding lesion of skin ulceration. In individuals with darker skin, discoloration, warmth, edema, induration, or hardness may be indicators.
Stage II Decubitus Ulcer
Partial thickness skin loss involving epidermis, dermis, or both. The lesion is superficial and presents clinically as an abrasion, blister, or shallow center.
Stage III Decubitus Ulcer
Full thickness skin loss involving damage or necrosis of subcutaneous tissue that may extend down to, but not through, underlying fascia.
Stage IV Decubitus Ulcer
Full thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures.
Direct Maternal Death
Death of a woman resulting from OB complications of the pregnancy,labor or puerperium (birth-6 weeks after delivery)
Indirect Maternal Death
Death of a woman from a previously existing disease that developed during pregnancy,labor or the puerperium that was not due to obstetric causes but although the physiologic effects of pregnancy were partially responsible for the death
Normal Distribution of Data
Most values in a set of data are close to the average Relatively few values tend to one extreme or the other, creating a Bell Shaped Curve
*Can only have specified values
*An exact number/not a fraction
*Ex. Number of children in a family
*Not restricted to certain specified values
*Can be a fraction
*Ex. Temperature 102.6, Height