Essentials of HIM: Ch 4 - Patient Record

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patient record

The business record for the patient encounter.

health care services

The patient record contains documentation of all _________ provided to patient.

demographic data, diagnoses, treatment, treatment results

The patient record is a repository of of information that includes ___________, and documentation to support _________, justify _________, and record ________.

demographic data

Patient identification information collected according to facility policy.

demographic data

Patient name, date of birth, place of birth, social security number, make up a patient's __________.

name, mailing address, telephone number

The facility must include its _______, _________, and _______ on each page of the patient record.

information capture

Process of recording representations of human though, perceptions, or actions in documenting patient care.

report generation

Process of analyzing, organizing, and presenting recorded patient information for authentication and inclusion in the patient's healthcare record.

continuity of care

Includes documentation of patient care services so that others who treat the patient have a source of information to base additional care and treatment.

quality of care, third-party payers, medicolegal, patient, facility, providers, research, education, policy-making

Secondary purposes of the record include: evaluating _____; providing information to _________ for reimbursement; serving the _______ interests of _____, ______, and ______; providing data for ______, _______, and ______.

provider

Who owns the patient record?

right to access, inaccurate, amended

The patient has the ___________ their record and request that ________ information be ________.

electronic health records

Computer based patient records

hospital inpatient record

Documents the care and treatment received by a patient admitted to the hospital

admitted

The hospital inpatient record documents care and treatment received by a patient ______ to the hospital.

nursing station

While at the hospital, the patient record is typically located at the ________.

administrative, clinical

All patient records contain ________ and _______ data.

administrative

Data that includes demographics, socioeconomic, and financial information.

clinical

Data that includes all patient health information obtained throughout treatment and care of patient.

administrative

Patient name, martial status, place of employment, date of birth, insurance number, and third-party payer are what type of data?

clinical

Physical and history, operative records, lab reports, discharge summary, progress notes are what type of data?

hospital outpatient record

Documents services received by a patient who has not been admitted to the hospital overnight.

ancillary, emergency department, outpatient surgery

The hospital outpatient record contains information about ______ services, _______ services, and _________.

physician office record

Documents patient health care services received in a physician's office.

authorized

The Joint Commission states that only ________ individuals may make entries in the medical record.

federal and state laws, accreditation, professional, legal

Health care providers are responsible for documenting care, treatment, and services in a manner that complies with _________ as well as _______, _______, and _______ standards

documented, done

Providers must abide by the phrase, "If it wasn't ______, it wasn't ________.

patient, third-party payer, refuse to pay

If the provider performs a service, but doesn't document it, the ________ or _________ can ________ for service

defense, quality of care

Patient record can serve as an excellent _______ of the _______.

authentication

All patient record entries require _______.

authentication

An entry is signed by the author of the document.

author, accurate, verified

CMS specifies that only the _______ of an entry can authenticate that entry, thus establishing that the entry is ____ and has been ______ by the author.

written signatures, countersignatures, initials, fax signatures, electronic signatures, signature stamps

Documents can be authenticated through these six methods:

first initial, last name, title/credential or discipline

At a minimum, the facility must require the providers to sign with their _____, ______, and _________.

countersignatures

Form of authentication by an individual in addition to the original author of entry.

countersignatures

___________ are required when nurses and other authorized personnel document a verbal order from a physician.

24 hrs

Verbal orders, specifically telephone orders, must be authenticated by responsible physician within _____ of documentation.

signature legend

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

electronic signature

Refers to various methods by which an electronic document can be authenticated.

Certificates of Medical necessity, durable medical equipment

Medicare does not allow the use of signature stamps on ___________ for ___________.

30, 24 hrs

CoP requires a complete physical exam to be performed no more than _______ days prior to admission or within ______ after admission

48 hrs

CoP requires report of physical exam must be placed in patient record within ______ after admission.

24 hrs

JC requires the H & P to be documented in the patient record within _______ of inpatient admission.

30 days

JC requires patient records to be completed _______ after the patient is discharged.

delinquent

After 30 days, incomplete patient records are considered __________.

author

The only person authorized to correct an entry in the record is the ________ of the entry.

single line, incorrect information, date, time, sign, reason for the error, as close as possible, correct information, as close as possible

To amend the patient record, the provider needs to: draw a _________ through the __________; ______, _____, and ______ the corrected entry; document a _______ in a location _________ to original documentation; enter the __________ in a location ________ to original documentation.

audit trail

Electronic health records will automatically create a list of all changes made to patient documentation. This is called an:

written statement, disagreeing

If the covered entity denies the request to amend or correct the record, the individual can submit a _______ ________ with the denial.

addendum

Method to amend the record that provides additional information about previous documentation. It is also used to enter a late entry.

addendum, clarification, late entry, current date, time, original date, time, authenticate, reason

When adding an addendum, the provider should: document the word _________ or _________ or _______; document the _________ and ________ as well as ______ and ______; ________ the addendum; provide the _________ for the addendum.

falsification, tampering

If routine review of patient records reveals missing information and hospital staff fill in missing information as the result of an audit, this is considered _____________ of records or ________ with the record and is illegal.

preadmission testing

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

chest x-ray, ekg, lab tests

Three common types of preadmission testing that are done are:

demographic information, course of treatment, discharge information

The patient record consists of three major sections. They are:

provisional diagnosis

This is obtained from the attending physician and is the diagnosis upon which patient care is based.

working, tentative, admission, preliminary

Provisional diagnosis is also known as ______, ______, ______, or _______ diagnosis.

face sheet

Demographic data is usually documented on the ______.

attending physician

This person is responsible for performing an admission history and physical exam on the patient in a hospital.

attending physician

This person is responsible for dictating a discharge summary to document care provided to patient during inpatient hospitalization.

reason for hospitalization, course of treatment, condition at discharge

A discharge summary includes which three things?

reverse chronological order

Documents are organized from the most current document to least current document.

chronological order

Documents are organized from least current to most current document.

reverse chronological order, chronological order

Most facilities organize the patient record in _______ during inpatient hospitalization, and ________ once patient is discharged.

universal chart order

When facilities organize reports in same order for both inpatient and discharged patient records, the facility is using a:

manual record

Patient record in paper format.

primary source

Records that document patient care provided by health care professionals

secondary source

Contain data abstracted from primary sources of patient information.

secondary sources

Indexes, registers, committee minutes, incident reports are examples of:

incident report

Collects information about a potentially compensable event, an accident or medical error that results in personal injury or loss of property.

note, report, patient record

Do not enter a _______ in the record that an incident report has been completed. Do not file an incident _____ in the _________.

source oriented record

Type of patient record format that organizes information according to source of documentation.

sectionalized

Record that is subdivided into sections.

sectionalized

A source oriented record is ___________.

easier

An advantage of a source oriented record is that its _______ to find information.

hard to follow

A disadvantage of a source oriented record is that its _________ a particular diagnosis.

problem oriented record

Type of patient record format that more systematic and consists of four components

database, problem list, initial plan, progress notes

The problem oriented record consists of what four sections?

database

In a problem oriented record, this contains a minimum set of data such as chief complaint, conditions and diagnoses, social data, history, physical exam, and baseline lab data.

problem list

In a problem oriented record, this acts as a table of contents for the patient record.

problem list

In a problem oriented record, this contains a list of the patient's problems.

initial plan

In a problem oriented record, this contains the strategy for management of the patient's care and describes actions that will be taken to learn about patient's condition and treat/educate patient.

strategy for management, action, learn, treat/educate

In a problem oriented record, the initial plan contains the _____ of the patient's care and describes _____ that will be taken to _____ about patient's condition and ______ patient.

diagnostic/management, therapeutic, patient education

The initial plan in POR contains these three types of plans.

soap

In the problem oriented record, problems and notes are documented using the _________ structure.

subjective, objective, assessment, plan

SOAP stands for:

subjective

In the POR, this section of the progress notes provides the patient's statement about how she feels, including symptomatic information.

objective

In the POR, this section of the progress notes provides observations about the patient including physical findings or lab/x-ray results.

assessment

In the POR, this section of the progress notes provides judgment, opinion, or evaluation made by health care provider.

plan

In the POR, this section of the progress notes provides diagnostic, therapeutic, and educational solutions to resolve the problems.

integrated

Type of patient record format that usually arranges reports in strict chronological date order.

integrated

This type of patient record allows for observation of how patient is progressing according to test results and how patient responds to treatment.

easy to follow diagnosis

An advantage of the problem-oriented record.

training, time-consuming

Disadvantages of the POR are that it requires _______ and is ________.

organized, easy to use, time-consuming

Advantages of the integrated record are that it is highly _____, ______, and less ______.

compare, retrieve

With integrated records, typically it is difficult to ______ and _____ information.

archived records

Records placed in storage and rarely accessed are called:

retention period

Length of time a facility will maintain an archived record.

federal and state laws

The retention period for records is based on ___________.

digital archive

A storage solution that consolidates electronic records on a computer server for management or retrieval.

shadow record

Paper record that contains copies of original records and is maintained separately from the primary record.

purge

Many providers opt to ________ and convert paper-based records to microfilm or optical disk.

five years

CoP requires hospitals, long term care facilities, specialized providers and home health agencies to retain records for a period of no less than _______.

statute of limitations, age of consent

Some states establish time frames for record retention based on _________ and __________.

statute of limitations

The time period during which a person may bring forth a lawsuit.

age of consent

States that govern the __________ require facilities to retain records for a time period in addition to the retention law.

accreditation organizations

_____________ do not mandate record retention schedules.

five year

American Hospital Association recommends a ________ retention period for records.

10 years, permanently

AHIMA recommends that operative indices be retained for a minimum of _______ and the operating room register _________.

record retention schedule

Outlines the information that will be maintained, the time period for retention, and manner in which information will be stored.

maintained, time period, manner

The record retention schedule outline the information that will be ______, the _______ for retention, and _______ in which the information will be stored.

accreditation agency, federal and state, legal, research/educational

Record retention schedules should be established based on: ______ recommendation, _______ laws, _______ requirements, _______ uses.

off-site storage

Used to store records at a location separate from the facility.

cost, storage, transportation, security, access

What are five considerations when selecting an off-site storage facility?

certificate of destruction

After destruction, a ______________ is produced and permanently maintained.

date, method, supervisor, destroyed records, disposal, normal course of business

A certificate of destruction should have a ______ and _____ of destruction, signature of ______, listing of _________, dates of ________, and __________.

acid, incineration, pulping, shredding

Four methods of paper record destruction include:

notified, closure, new location

When a facility closes, patients must be _______ of _______ and ________ of records.

part of the sale

When a facility is sold to another health care entity, records are considered _______.

governing body

This group is responsible for ensuring high quality medical care and that care is documented as part of a complete and accurate record.

facility administration

This group is responsible for ensuring that the medical staff adopts rules and regulations for maintaining records and enforcing medical record policies.

high quality, complete, accurate

The governing body is responsible for ensuring _______ medical care and that care is documented as part of a __________ and _______ record.

medical staff, medical record

The facility administration is responsible for ensuring that the ________ adopts rules and regulations for maintaining records, and enforcing __________ policies

health information manager

This person is responsible for educating physicians/health care providers about proper documentation procedures and policies.

health information staff

These people assist in design of patient record systems to facilitate sound record documentation practices and performs record completion tasks.

record assembly

This involves organizing discharged patient records according to accepted chart order and preparing for storage.

organized, chart order, storage

In record assembly patient records are _______ according to accepted ________ and prepared for ________.

quantitative analysis

This involves the review of the patient record for completeness, and identification of chart deficiencies.

completeness, deficiencies

In quantitative analysis, the record is reviewed for _______ and _______________.

qualitative analysis

This involves the review of the patient record for inconsistencies that may identify incomplete or inaccurate documentation.

inconsistencies, incomplete, inaccurate

In qualitative analysis, the record is reviewed for _________ that may identify ________ or _______ documentation.

concurrent analysis

This involves the review of the patient record during inpatient hospitalization to ensure quality care through quality of documentation.

inpatient hospitalization, quality care, quality of documentation

In concurrent analysis, the record is reviewed during ____________ to ensure _________ through _________.

statistical analysis

This involves abstracting data from patient record for clinical/administration decision-making.

abstracted, clinical/administration decision-making

In statistical analysis, data is ________ from patient record for _____________.

identify

A primary purpose of the patient record is to _____ the patient.

diagnosis, care, treatment, services provided

The primary purpose of the patient record is to support and justify the patient's ______, _____, _____, and ______.

course of treatment, results

The primary purpose of the patient record is to document the _______ and ______.

continuity of care

The primary purpose of the patient record is to facilitate _________.

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