Documents organized into sections according to the provider's and departments that provide treatment (lab together, rad. together, clinical notes together)
Problem-Oriented Health Record
Divided into four parts: database, problem list, initial plan, progress notes (SOAP)
SOAP what does S stand for?
Subjective (patient's point of view)
SOAP what does O stand for?
Objective (what the practitioner finds)
SOAP what does A stand for?
Assessment (combine subjective and objective to make a conclusion)
SOAP what does P stand for?
Plan (approach to be taken to resolve patient's problem
Integrated Health Records
Documentation from various sources organized in strict chronological or reverse chronological order
Advantage of Integrated Health Record?
Easy to follow course of diagnosis and treatment
Disadvantage of Integrated Health Record?
Difficult to compare similar information (ex. lab results or oncology information)
When should H&P be documented in record?
Within 24 hours of admission
When should Operative Report be documented in record?
Immediately following surgery
When should Verbal Orders be cosigned?
Within 24 hours
When should Discharge Summary be documented?
Immediately after discharge of patient
Review of record to ensure that standards are met and determine the adequacy of entries documenting the quality of care
A review of health record to determine its completeness and accuracy
Data are the correct values and are valid
Data items are easily obtainable and legal to collect
All required data items included AND entire scope of data is collected and intentional limitations documented
Value of data is reliable and consistent across applications
Data is up to date, if it is outdated it must have been up to date at the time it was presented
Clear definitions provided so users know what data means, each data element should have clear meaning and accepted values
The attributes and values of data should be defined at the correct level of detail
Data values should be just large enough to support the application or process and acceptable values or ranges must be defined
The data are meaningful to the performance of the process or application for which they are collected
Determined by how the data are being used and their context
Minimum Data Set (MDS) purpose?
Promote comparability and compatibility of data by using standard data items with uniform definitions
Uniform Hospital Discharge Data Set (UHDDS)
Uniform collection of data on inpatients
Uniform Ambulatory Core Data Set (UACDS)
Improve ability to compare data in ambulatory care settings
Minimum Data Set (MDS) for Long-Term Care (LTC) and Resident Assessment Instrument (RAI)
Comprehensive functional assessment of long-term care patients
Outcome and Assessment Information Set (OASIS)
Comprehensive assessment for adult home care patient and forms the basis for measuring patient outcomes
Uniform Clinical Data Set (UCDS)
Data collection utilized by peer review organization to determine the quality of patient care
Data (3 definition points)
1. Collection of elements on a given subject 2. Raw facts and figures expressed in text, numbers, symbols, and images 3. Facts, ideas, or concepts that can be captured, communicated, and processed, either manually or electronically
Information (2 definition points)
1. Data that have been processed into meaningful form, manually or by computer in order to be valuable to user 2. Adds to a representation and tells recipient something that was not known before
Plan or pattern for an information system, including the database structure, known as a conceptual model, and the translation of the concept to the computer, known as the physical model
Persons, locations, things, or concepts about which data can be collected and stored
Describes an entity or distinct characteristics about it
Associations between entities
Collection of bits make up a byte
A character such as a number, letter, or symbol
Made up of several characters such as name, age, or gender
Made up of a series of fields about one person or thing
Made up of fields and records about an entity such as a patient
What is another word for file or entity
What are fields in a database table?
What are records in a database table?
Relational Model Database
Database management system in which data are organized and managed as a collection of tables
Object Oriented Database Model
Uses commands that act as small, self-contained instructional units (objects) that may be combined in various ways
Hierarchical Database Model
Data is organized in tree's according to relationships (one to many)
Network Database Model
Data is organized in tree's according to relationships (many to many)
Open System Architecture
Hardware, software, transmission, media, and database industry standards allow different computer vendor systems to communicate to each other
Closed System Architecture
Communication is possible only on one vendor's system
Physical equipment that makes up computers and computer systems
What are the 3 types of computers?
Mainframes, minicomputers, microcomputers
Operating systems software and application software
Local Area Network (LAN)
Multiple devices connected via communications media and located in a small geographical area
Wide Area Network (WAN)
A computer network that connects separate institutions across a large geographical area
Private network that has its servers located inside a firewall
Alphabetic Health Record Identification
A patient's name identifies the patient record
A number identifies the patient record
A new number is assigned to the patient for each new encounter at the facility
The patient retains the same number for every encounter at the facility
A new number is assigned to the patient for each new encounter at the facility, but the former records are brought forward and filed under the new number
Records filed in one location
Records filed in multiple locations
Starts with last names and then includes first name and middle initial
Straight Numeric Filing
Filing charts in sequential order; the records start with the chart with the lowest number value and end with the chart with the highest number value
Terminal Digit Filing
Numeric filing is divided into three parts and is read from right to left instead of left to right
What does AHA recommend for record retention?
Minimum of 10 years
When does AHA recommend record retention for a minor?
10 years past the age of majority
Listing or arrangement of data in a designated order; contains special types of information, and purpose is to assist in location of desired information
Master Patient Index (MPI)
Identifies all patients admitted to a health care facility for treatment, along with their identifying information
Chronological list of patient's identification numbers issued to patients
Provides every physician with a list of identifying medical cases
List of diseases and conditions according to the classification system used in the facility
Procedure or Operation Index
List of surgical and procedural codes
Created to monitor various diseases and health problems with different goals and objectives
Admission and Discharge Register -- How long retained and in what order?
Permanent in chronological order
Operating Room Register
Maintained for 10 years; provides statistical data for caseload analysis and administrative reports
Births and Deaths Register
Provide accessible information about births and deaths
Emergency Room Register
Monitors patients who enter the emergency room for services
Cancer or Tumor Registry
System that monitors all types of cancer diagnosed or treated in an institution
Health Care Information Management Systems Society (HIMSS)
Provides leadership in health care for the management of technology management systems
International Federation of Health Record Organizations (IFHRO)
Supports national associations and health record professionals to improve health records
International Medical Informatics Association (IMIA)
Promotes informatics in healthcare and bio-medical research
American Medical Informatics Association (AMIA)
Supports information technology professionals to improve health care
American Association for Medical Transcription (AAMT)
Largest association for medical trasncription
College of Healthcare Information Management Executives (CHIME)
Serves needs of health care chief information officers and advocates for more effective use of information management in health care
Alternate Delivery Systems
Health care provided by methods other than the traditional inpatient care, including home health, ambulatory, hospice, and other types of health care.
The management of, responsibility for, or attention to the safety and well-being of another person or other persons
Individual who is receiving professional services
Hill Burton Act
Legislation enacted in 1946 that provided funding for the construction of hospitals and other health care facilities
Secondary Patient Record
A record used for selected data elements to aid in research conducted by clinical and non-clinical people
American Medical Association (AMA) was established to...?
Assure the quality of American medical education
American Hospital Association (AHA) was established to...?
Promote public welfare by providing better health care in hospitals
What did the Flexner Report of 1910 do?
Identify serious problems and inconsistencies in medical education
American College of Surgeons (ACS) was established to...?
Develop a system of hospital standardization to improve patient care and recognize hospitals that had the highest ideals
What is the Department of Health and Human Services (DHHS) responsible for?
Health issues, including health care and cost, welfare of various populations, occupational safety, and income security plans
What did the Tax Equity and Fiscal Responsibilities Act (TEFRA) do?
Established a mechanism for controlling the cost of the Medicare program and set limits on reimbursement and required the development of the prospective payment system
What did the Consolidated Omnibus Budget Reconciliation Act (COBRA) establish?
Anti-dumping statue, established criteria for the transfer and discharge of Medicare and Medicaid patients
What did the Patient Self-Determination Act of 1990 establish?
Gave patients the right to set advance directives
Hierarchical Organizational Chart
Individuals at the top have authority and it passes downward through a chain of command
Vertical Organizational Chart
Governing Board has ultimate authority, followed by the CEO, Medical Staff, Department Directors, Supervisors, and Numerous Subordinates
Matrix Organizational Chart
Supports general managers who focus on managing people and processes as opposed to strategy and structure, horizontal scheme embraces individual capabilities, employees may have two or more supervisors
Product Line Management
Hospitals organized around product line categories (obstetrics, rehabilitation, cardiology)
Health Maintenance Organizations (HMO's)
Managed health care that integrates health care delivery with insurance for healthcare
Nursing Long-Term Care
Nursing care and related services for residents who need medical, nursing, or rehabilitative care provided on a 24 hour basis
Supervision, room, and board provided for those unable to live independently
Mobile Diagnostic Services
Health care services are transported to the patients, especially diagnostic procedures
Fee for Service
Third party payers and/ or patients issue payments to health care providers based on charges assigned to each service performed for each patient
Third party payers and/ or patients pay health care providers after services have been rendered
Costs are controlled by the managed-care plan's management of members' uses of services; providers are reimbursed by fee schedules
Episode of Care
Health care plan compensates providers with a lump-sum payment to compensate them for all services delivered to a patient for a specific illness and over a specific period of time
Resource-Based Relative Value Scale (RBRVS)
for reimbursement of physician services of beneficiaries covered under Medicare Part B
Clinical Practice Guidelines
Systematically developed statements used to assist provider and patient decisions about appropriate health care for specific clinical circumstances
Treatment recommendations often based on guidelines, step-by-step description of an accepted procedure
Display goals for patients and provide the corresponding ideal sequence and timing of staff actions to achieve those goals with optimal efficiency
Structured plans of care
Multi-disciplinary standards that outline the processes of care and expected outcomes within predetermined time frames
Private Law (Civil Law)
Recognition and enforcement of the rights and duties of private individuals and organizations
An injury or wrong committed against an individual or his property. One party asserts wrongful conduct on part of the other and seeks compensation for harm suffered
Legally enforceable agreements between two or more individuals
Deals with relationships between private parties and the government (criminal law and government regulations)
Prohibits conduct considered injurious to society as a whole and provides for punishment of those found to have engaged in such conduct
What is the difference between a CRIME and a TORT
A crime is an offense against a person or the public at large. A tort is a civil wrong against an individual
Statutory law written or enacted by bodies such as the U.S. Congress and state and local legislatures
Consists of principles that have evolved over time from court decisions resolving controversies
How long does AHIMA recommend keeping an adult patient health record?
10 years after most recent encounter
How long does AHIMA recommend keeping a minor patient health record?
From the age of majority (usually 18) plus a statute of limitation governing medical malpractice lawsuits
Who owns the physical health record?
The healthcare provider, physician, or hospital that maintains it
Who owns the information within the health record?
The right of an individual to be left alone
What are the three elements of privileged communication?
1. Relationship between patient and provider 2. Information must have been acquired through such a relationship 3. Information must have some connection with the provider's task of treating the patient
Durable Power of Attorney
Legal document in which patients name someone close to them to make decisions about their health care in the event they become incapacitated
Court order requiring someone to appear in court to give testimony
What can happen if you disregard a subpoena?
You can be held in contempt of court
Subpoena Duces Tecum
A written order commanding a person to appear, give testimony, and bring all documents(records) described in the subpoena to court
Subpoena Ad Testificandum
Court order that requires a person to appear in court to testify
Drug Abuse and Treatment Act (1972)
Requires drug and alcohol abuse patient records to be kept confidential and not subject to disclosure except as provided by law
Heath Care Quality Improvement Act (1986)
Established the NPDB
Patient Self Determination Act (1990)
Requires that all health care facilities notify patients age 18 and over that they have the right to have an advance directive placed in their health record
Privacy Act (1974)
Gives individuals some control over the information collected about them by the federal government
Omnibus Budget Reconciliation Act (1987)
Created the Nursing Home Reform Act, which ensures residents of nursing homes receive quality care, requires provision of certain services, and establishes a residents' bill of rights
Tax Equity and Fiscal Responsibility Act (1936) TEFRA
Introduced the Peer Review Organization (PRO) program as a component of Medicare law to ensure the quality of care rendered to patients
Uniform Business Records as Evidence Act (1936)
Stipulates that records can be admitted as evidence in a court of law if they were kept in the ordinary course of business.
Uniform Healthcare Information Act (1985)
Serves as a model for state adoption and provides rules about health information management. As of 1996, only Montana and Washington had enacted this legislation