75 terms


data precision
the extent to which data have the values they are expected to have
data applications
the purposes for which data is collected
data comprehensiveness
the extent to which healthcare data are complete; data complete all required elements
data definition
the specific meaning of a heathcare related data element
data collection
the processes by which data are collected
data accuracy
the process by which data are free of identifiable errors; data are correct
data consistency
the extent to which data are reliable; that the dates of birth and all information is the same
data warehousing
the processes and systems by which data are archived
data accessiblity
the extent to which healthcare data are obtainable; data is easy to obtain
data currency
the extent to which data are up to date; making sure that data is input in record at time of occurence
data availability
the extent to which healthcare data are accessible whenever and whereever they are needed
data analysis
the processes by which data are translated into information that can be used for designated applications
the dates, number, image, symbol, letter and words that represent basic facts observations about people processes, measurements and conditions
the expectation that the personal information shared by an individual with a healthcare provider during the course of care will be used only for its intended purpose
the right of individuals to control access to their personal health information
the protection of privacy of individuals and the confidentality of health records
problem oriented health record format
a documentation approach in which the physician defines each clinical problem individually four components, the database, the problem list, initial plans and progress notes
integrated health record format
organizes all the paper forms in strict chronological order and mixes the forms created by different departments
source oriented health record format
organizes the information according to the patient care department that provided the care
clinical decision support
an information system that will assist physicians in diagnosing and treating patients.
government policy maker
an institutional user of the health record
the expectation that personal information shared by an individual with a healthcare provider during the course of care will be used only for it intended purpose
paper based records
do not have built in access control mechanism
data and information is not the same meaning
data is raw facts and figures and information is data converted into meaningful format
secondary purpose for health record
support for research; bioterrorism
primary purpose of the health record
use of a health record by a clinician to facilitate quality patient care is considered
How do accreditation organizations use the health record
to determine the standards are being met
how do research organization use the health record
to examine results of experimental protocals
attorneys for healthcare organizations use the health record to
protect the legal interest of the facility and healthcare providers
source oriented health record
our record has all lab report, progress reports, and so on filed together in separate sections of the health record
inaccurate data recorded in the health record
compromise quality patient care, contribute to incorrect assumptions by policy makers, invalidate research findings
computerized physician/ provider order entry
since we implemented a new technology, we eliminated lost orders and problems with legibility
patient care managers are
individual user of the health record
storing patient care documentation
is the most important function of the health record
healthcare info systems need to exchange info, this linkage between systems is called
data granularity
a numerical measurement carried out to the appropriate decimal place
are more stringent
EHR systems do not have the same access control requirements as paper based because they are more
who, what, where, when, how, and why
the health record is the storage place for data and information about the healthcare services to an individual patient. It documents the ______,______, ________, ______, _______.and _____ of patient care
what is the function of the health record
planning and managing care, evaluating adequacy and appropriateness of care, substaining reimbursement claims, protecting legal interests of both patient and healthcare provider
records of immunizations
the type of data not normally documented in the acute care health record
providing info about the patients insurance coverage
this is not a function of the discharge summary
patients consent to undergo treatment can be expressed in
by his or her submission to treatment, written agreement, verbal agreement
name of insurance company
an example of clinical data is progress notes, physician orders, and admission diagnosis, but what is not a type of clinical data
federal laws resulted in the new privacy regulations for healthcare organizations
operative report
a report that includes names of surgeon and assistants, date, duration, and description of the procedure and any specimens removed
a living will
an example of an advanced directive
Patients complete medical history
is not normally documented in a emergency care documentation
intermediate care facilities
which long term care facility is not governed by medicare
Outcomes and assessment information set
A specialized patient assessment tools must be used by Medicare certified home care providers
medicare conditions for coverage
regulations that are most commonly applied in end stage renal disease treatment
never obliterate data
what you should never do to data that incorrect in a medical record to make a correction
see accreditation from JOINT COMMISSION
acute care hospitals, psychiatric hospitals, home care providers, and ambulatory care organizations
the federal conditions of participation apply to which type of healthcare organization?
any organization that treats Medicare and medicaid patients
not a traditional health record format
process oriented health record
hybrid record
the health record format that is most commonly used by healthcare settings as they transition to EHR
data dictionaries
of the following which is not an example of data capture technology; bar code readers, data dictionaries, optical character readers, continuous voice recognition
the health record contains the statement as a SOAP note; the patient will be placed on IV antibiotics and blood cultures will be taken this is an example of
all of the above
which of the following factors should be considered when designing a data retrieval system for an EHR? presentation of data, quick search capablilities, need to know, and analytical capablities
the end result of a review process that shows voluntary compliance with guidelines of an external non profit organization
progress notes of physicians, nurses, therapists, and other authorized individuals would be found together in chronological sequence in a ______ paper record
chief complaint
which part of a medical history documents the nature and duration of the symptoms that caused a pt. to seek medical attention as stated in the patient own words
progress notes
creates a chronological report of the patients condition and response to treatment during a hospital stay
medical staff by laws
determines who can receive and transcribe verbal orders
problem list
which is not usually a component of the acute care patient records ; medical history, nurse assesment, problem list, progress notes
discharge summary
the attending physician is responsible for which of the following types of acute care documentation
medication record
a nurse is responsible for which of the following types of acute care documentation
admitting diagnosis
what is an example of clinical data? admitting diagnosis, data and time of admission, insurance information, health record number
operative report
the number of ligatures, sutures , packs, drains, and sponges used and specimens removed would be found in the: anesthesia report, progress notes, operative report, recovery room report
emergency care record
which type of specialized record includes care provided prior to arrival at a healthcare setting and contains the times and means of arrival? ambulatory care record, emergency care record, ambulatory surgery record,pediatric record
all of the above
documentation standards and guidelines are published by a variety of private and public organizations, including the ______. Joint commssion, american health information management association, national committee for quality assurance
can be accessed by multiple end users simultaneously
which of the following is true of computer based records? is usually supported by all healthcare providers, can be assessed by multiple end users simultaneously, has a clear definition and technological standards, permits minimal risks to healthcare privacy and security
medical history
which of the following represents documentation of the patients current and past health status?
physical exam
which of the following contains the physicians findings based on an examination of the patient
consultation report
documents opinions about the patients condition from the perspective of a physician not previously involved in the patients care
function of physicians orders
to document the physicians instructions to other parties involved providing care to the patient