Health Information Management

Created by mtdeae 

Upgrade to
remove ads

Chapter 4 The patient Record Hospital, Physician Office, and Alternate Care Settings

Alternate Care Facilities

Alternate Cares Facilities that provide behavorial health, home health, hospice, outpatient, skilled nursing, home health, and other forms of care also serve as a documentation source for patient care information

Patient Care Record

serves as the business record for a patient encounter, contains documentation of all healthcare services provided to a patient, and is a repository of information that includes demographic data, as well as documentation to support diangnoses, justify treatment, and record treament result.

Demographic Data

patient identification information that is collected according to facility policy(e.g., patient's name, date of birth, mother's maiden name, and Social Secuirty number).

Information Capture

"The process of recording representations of human thought, perceptions, or actions in documenting patient care, as well as device-generated information that is gathered and/or computed about a patient as part of health care "

Medical Transcriptionist

listens to dictated information and keyboards the report

Medical Transciption

involves a keyboard medical information dictated by a provider.

The owner ship of patient records

The ownership is the property of the provider, and as governed by federal and state laws, the patient has the right to access it contents for review and to request that inaccurate information be amended.

hospital inpatient records

documents the care and treatment received by a pateint admitted to the hospital

Hospital Outpatient or Hospital ambulatory care record

Documents services received by a patient who has not been admitted to the hospital overnight and includes ancillary services, emergency department services, and outpatient surgery.

Auto-Authentication

involves a provider authenticating a dictated report prior to its transcription.

Authentication

an entry is signed by the author

Countersignature

is a form of authentication ny an individual in addition to the signature by the orginal author of an entry.

Telephone Order (T.O)

is a verbal order taken over the telephone by a qualified professional from a physician.

Voice Order or verbal order

is an order where the physician dictates an order in the presence of a responsible person.

signature legend

is a document maintained by the health information department to identify the author by full signature when initials are used to authenticate entries.

Electronic signature

is a generic term that refers to the varous methods by which and electronic doument can be authenticated

Digital signature

which is created using public key cryptography to authenticate a document or message

Public Key Crytography

uses an algorithm of two keys, one for creating the digital signature by transformating datat into a seemingly unintelligible form and the other to verify a digital signature and return the message to its original form

ASTM-1762-Standard Guide for Authentication of Healthcare Information

Is intended to complement standards developed by other organizations

ASTM-1762-Standard Guide for Authentication of Healthcare Information

A document structure for use by eletronic signature mechanisms
The characteristics of an electronic signature process
Minimum requirements for different eletronic signature mechanisms
Signature attributes for use with electronic signature mechacanisms
Acceptable eletronic signature medchanisms and technologies
Minimum requirements for user identification access control, and other security requirements for electronic signatures
Technical details for all electronic signature mechanisms in sufficient detail to allow interoperability between systems supporting the same signature mechanism

Abbreviation List

include medical staff approved abbreviations, acronyms, and symbols that can be documentd in patient records.

Amending the patient Records

correcting documentation in the patient record. The only person authorized to correct an entry is th eauthor of the orginal entry.

audit trail

is a technical control created by an electronic health record system and consist of a listing of all transactions and activities that occured.

Addendum

clarify or avoid incorrect interpretation of informaiton about previous documentation or enter a late entry. The purpose to addendum is to proved addional information, not to change documentation, and the addendum should be documented as soon after the original entry as possible.

Preadmission testing (PAT)

incorporates pateint registration, testing, and other services into one visit prior to inpatient admission, adn the results are incorporated into the patient's record.

provisional diagnosis

( or working, tentative, admission, preliminary diagnoses), which is obtained from the attending physician ad is the diagnosis upon which patient care is based

patient representative

the person who has legal responsbility for the patient signs an admission consent form to document consent to treatment.

nursing assessment

documents the patient's history, current medications, and vital signs on a variety of nursing forms, including nurses notes, graphic charts, and so on.

reverse chronologial data order

means that the most current document is filed first in a section of records

Chronological order

Discharged patients informaiton is the oldest is filed first in a section

solo practioner

a physician who practices alone, are typically not as structerd as records created for group practices

mHealth

refers to the use of wireless technology to devisions while reducing the cost of care and improvingconvenience to caregivers

Signature Stamps

are authorized for use in a facility, the provder whose signature the stamp represent must sign a statement that she or he alone will use the stamp to authenticate documents.

Primary sources

Records that document patient care provided by health care professionals

Incident Report

collects information about a potentially compensable event

potentially compensable event (PCE)

is an accidnet or medical error that results inpersonal injury or loss of property

Source Oriented Record (SOR)

maintains reports according to source of documentation. This means that all documents generated bu the nursing staff are located inn a nursing section of the record, radiology reports in a radiollogy section, and physisican generated in the miedical section.

Problem Oriented Record (POR)

a more systematic method of ducumentation, which consists of found components: Database, Problem list, Initial plan, Progress notes

Data

contains a minimum set of data to be collected on every patient, such as cheif complaint, present conditions and diagnosis; social data; past personal, medical, and social history and baseline labortory data

Diagnostic/management plans

plans to learn more about the patient's condidtion and the management of the condition

Therapeutic plans

specific medications, goals, procedures, therapies, and treatments used to treat the patient

Patient education plans

plans to educate the patient about conditions for which the patient is being treated

SOAP

a structure in a POR, each patient is assigned one or more problems and notes are documented

Subjective (S)

Patient's statement about how she feels, including, symptomatic infomration (e.g headache)

Objective (O)

Observations about the patient, such as physical findings or lab or X-ray results (e.g. chest X-ray negative)

Assessment (A)

judgement, opinion, or evaluational made by health care provider (e.g. acute migraine)

Plan (P)

diagnostic, therapeutic, and educational plans to resolve the problems (e.g. patient to take Tylenol as needed for pain)

archived records or inactive records

Records placed in storage and rarley accessed

Retention period

Those stored in paper format create the need for a large filing area; therefore, each facility should develop policies that indicate the length of time a facility will maintain and archieved record.

Shadow record

a paper record that contains copies of orginal records and is maintained separately from primary records (pg.93)

Independent database

contains clinical infromation created by researchers, typically in academic medical center

Purge

remove inactive records from the file system

statue of limitation

the time period during which a person may bring forth a lawsuit

age of consent

age of majority, which means facilites must retain records for time period (e.g., 18 years) in addition to the retention law.

record retention schedule

This schedule outlines the information that will be maintained, the time period for retention, and the manner in which information will be stored. Records can be stored on paper, microfilm, magnetic tape, optical disk, or as part of an electronic system.

When developing a record retention schedule, consider the following

Accreditation agency recommendations, Federal retention laws, Legal requirements, Need for continuing patient care, research/ education uses, State retention laws

Alternative storage method

off-site storage, microfilm, or optical imaging

Off-site storage or remote storage

is used a to store at a location separate from the facility

Microfilm

is a photographic process that records the original paper record on film, with the film image apperaring similar to a photograph negative (e.g.,the paper record is prepared according to the same method used for scanning)

Aperture card

Punched card onto which frames of a microfilmed document are mounted.

Cartridge film

Roll film that is stored in a plastic cartridge for protection and holds multiple patient records.

Jacket film

Individual images stored in 4X6 inch plastic sleeves, which contain multiple rows per page.

Microfiche film

A 4X6 Mylar film strip that holds thousands of images of multiple patient records.

Roll film

Continuous strip of film that holds thousands of images of mutiple patient records (roll film is often stored on a plastic reel)

Record destruction methods

for paper records usually include dissolving reords in acid incineration, pulping or pukverizing (crush into powder), or shredding

magnetic degaussing

alters magnetic fields on a computer medium

Record Assembly

Process of organizing discharged patient record according to chart order and preparing it for storage

Quantitative Analysis

Review of patient record for completeness, including identification of chart defiencies, which include missing reports and other documentation and missing sinatures.

Deficiency slip

is used to record chart deficiencies that are flagged in the record

Chart deficiencies

include missing reports and other documentation and missing signatures

Concurrent Analysis

Review of patient record for inconssistencies that may identify incomplete or inaccurate documentation, indluing review of final diagnoses or prcedures on the face sheet

Statistical Analysis

Abstracting data from the patient record for clinical or administrative descision making.

Please allow access to your computer’s microphone to use Voice Recording.

Having trouble? Click here for help.

We can’t access your microphone!

Click the icon above to update your browser permissions above and try again

Example:

Reload the page to try again!

Reload

Press Cmd-0 to reset your zoom

Press Ctrl-0 to reset your zoom

It looks like your browser might be zoomed in or out. Your browser needs to be zoomed to a normal size to record audio.

Please upgrade Flash or install Chrome
to use Voice Recording.

For more help, see our troubleshooting page.

Your microphone is muted

For help fixing this issue, see this FAQ.

Star this term

You can study starred terms together

NEW! Voice Recording

Create Set