DATA NEEDS/AMBULATORY CARE

12 terms by yattayah 

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ambulatory or outpatient care

patients arrive for treatment and leave after treatment is administered; they do not stay overnight

hospital-based
free standing

what are two principal categories of ambulatory care

hospital based ambulatory care

emergency department
hospital clinic
same-day surgery center
partial hospitalization program
ancillary services such as lab or x-ray
observation services(less than 24 hours)

free standing ambulatory care

physician office
university health centers
neighborhood health centers
ambulatory surgery centers
urgent care centers
birthing centers
renal dialysis centers

uniform care ambulatory data sets(UCADs)
data elements for emergency department systems (DEEDS)

what are data sets for ambulatory care providers

Uniform ambulatory care data set(UACDS)

1)approved by the NCVHS in 1989
2)includes segments that describe the patient, the provider, and the encounter

data elements for emergency department systems(DEEDS)

uniform specifications for data entered in ED patient records to reduce incompatibilities in ED records

DEEDS

patient identification data
facility and practitioner ID data
ED payment data
ED arrival and first assessment data
ED history and physical examination
ED procedure and results data
ED medication data
ED disposition and diagnosis data

centers for medicare and medicaid services
accreditation association for ambulatory health care
joint commission
commission on the accreditation birth center

what are examples of accreditation/certification agencies

unique health record requirements

1)ambulatory surgery centers must assure that each patient is evaluated by a physician or an anesthetist for proper recovery before discharge from the center
2)ambulatory surgery center provides each patient with written discharge instructions and overnight supplies
3)problem list

UHR requirements for medicare

certified ambulatory surgery centers, results of any preoperative diagnostic studies performed are entered into the medical record before surgery to evaluate the risk of anesthesia

emergency provisions available to operating rooms must include

emergency call system
oxygen
mechanical ventilator assistance
cardiac defibrillator and monitoring equipment
a trach set
laryngoscopes and endotracheal tubes
suction equipment

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