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Primary Data Source

Patient specific/identifiable data
Related to a specific individual
ex. The Health Record

Secondary Data Source

Information on groups of people or patients without identifying any particular patient individually.
Also called "Aggregate Data"
Compiled from multiple health records
Ex. Data taken from the health record and entered into registries and databases are considered secondary data.







Quantitative Analysis

Checking for the presence or absence of necessary reports or signatures. Ex. progress notes, orders
Completeness and Accuracy
Making sure a document is there and authenticated
Focuses on physician documentation

Qualitative Analysis

Ex. Checking documentation consistency, such as contraindications in entries,progress note dated prior to admission etc
Quality of records
Does documentation reflect the quality of patient care provided

Incident Report

Written accounts of unusual events that have an adverse effect on a patient, employee, or facility visitor.
Never filed in patient health record.
Used by risk management and or attorney to investigate incidents that have the potential to become claims against the organization or individual provider.


An event considered to be inconsistent with accepted standards of care.

res ipsa loquitor

"the thing speaks for itself"
The injury would not ordinarily occur without someones negligence Ex. Surgical instrument left in patient after surgery



Data Accessibility

data is available to those authorized to use it






Process of comparing an organization to a standard, a peer group, or other organization.
Ex. A hospital may want to compare its ALOS (average length of stay) with the ALOS for all hospitals nationwide.

Continuum Of Care

Various types of healthcare services provided in diverse settings from basic primary care to complex tertiary settings.

Primary Care

Services provided by physicians working in private offices, group practices, private clinics or community based clinics.
Ex Family practice, pediatrics
Ex of primary care services: preventative,routine screening,physical exams

Secondary Care

Diagnostic and theraputic services provided by medical specialists.

Tertiary Care

The provision of highly specialized and advanced diagnostic and therapeutic services in inpatient hospital settings.

The medical record is the property of the ........


The information in the medical record is owned by the.....


Legal Health record

Official business record of the healthcare orginization

Derived Data

Health information collected from health records
No patient identifiers


Raw facts and figures expressed in test, numbers symbols and figures


Data processed into meaningful form

Physician Index

Categorizes patient encounters by physicians


Database of patients that have a common characteristic


Reviewing/verifying the qualifications of physicians prior to granting privileges

National Practitioner Data Bank

Maintains information on medical malpractices claims against physicians

Reimbursement is based on...

Health record documentation


substantiates the need for services provided

Hospital Governing Board

Establishes medical staff policies regarding qualification criteria and process

Medical Staff executive committee

Reviews each practitioners applications and submits recommendations to governing board

Healthcare Integrity and Protection Data Bank

Maintains information on legal actions taken against licensed providers

Master Patient Index

Database of all patients treated a t a facility

Disease Index

Categorizes patient encounters by diagnosis
Arranged by diagnosis codes

Clinical Data

data related to the patients medical status and treatment
Medical record is the primary source of clinical data

Data Sets

particular data elements that are to be routinely collected


data elements to help practitioners improve the quality of care during emergency encounters

Data Validity

numbers, characters, or symbols stored, processed and displayed are exact and conform to known standards (correctness of data)
Ex. ICD-9CM code 250 (this code is not valid as it needs additional digits)

Data Reliability

data that is the same no matter who collected it or how many times it is collected
Ex. reliable data is consistent when entered into 2 or more databases

Data Completeness

All required data points are present
Ex. birthdate 1/31, this is not complete because the yesr is missing

Current Data

data is recorded at or near the time of observation

Data Timeliness

the period of time between recording or producing the data element and making the information available to users is short.

Data usefulness/meaningful

data must be relevant and understandable
Ex. the abbrev LOC appeared in a progress note, does it mean "laxitive of choice" or "loss of consciousness"

Principle Dx

The condition established after study to be chiefly responsible for admission of the patient to the hospital
Explains the reason the patient was admitted to the hospital

Secondary Dx

All conditions that coexist at the time of admission, that develop subsequently, or that affect the treatment received and/or length of stay.
Include comorbidities and complications


Any condition that coexists during the relevant episode of car and EFFECTS THE TREATMENT PROVIDED TO THE PATIENT
(what patient comes in the door with)
pre-exisiting condition that will affect treatment or increase the patients length of stay


Any condition that arises during the relevant episode of care and EFFECTS THE TREATMENT PROVIDED TO THE PATIENT
Ex. post-op complications, injuries that arise during the stay
Arises AFTER the patient s admission to the hospital

Principle Procedure

A procedure that was performed for definitive treatment rather than one performed for diagnostic or exploratory purposes, or was necessary to take care of a complication.

If you have 2 procedures that appear to be principle then the one most related to the......

principle diagnosis should be selected as the principle procedure

What 2 items are not a required data element of the UHDDS guidelines?

Admitting Dx
Patient Name

Admitting Dx

What the physician suspects is wrong with the patient
"tentative or provisional dx"

Juvenile Onset Diabetes

Type 1 Diabetes
Develops due to absence of insulin production (insulinopenia)
Not determined by age
Requires an injection of insulin to maintain normal glucose levels

Commonly Used Insulins

NPH Insulin

Adult On set Diabetes

Type 2 Diabetes
Formerly known as NIDDM (non insulin dependent diabetes mellitus)
Insulin Requiring Diabetes
Patient is not dependent on insulin to live
Prone to develop dehydration


abscence of insulin production

Impaired Glucose Tolerence

Dx given to people who have blood sugar levels higher than normal but not enough to be given the dx of diabetes

Brittle Diabetic

Blood sugars quickly swing from high to low and from low to high (unstable)

Extrinsic Asthma

patients with this type of asthma have a family hx of asthma

Review Of Systems

Physician asks patient a series of questions about how they feel.
Usually organized by body system
The physician does not touch the patient during ROS


Physicians opinion on what is wrong with the patient (admitting dx)

Timing of H&P

Must be documented within 24hrs of admission
Must be documented before surgery
Can be documented no more than 7 days prior to admission
If pt is readmitted within 30 days for the same condition the physician may use an "interval note"

Standing Orders

Orders established by a physician that apply to a particular dx or condition

Verbal Orders

Usually by telephone
According to Medicare Conditions Of Participation state verbal order should be authenticated within 48 hrs

Discharge Orders

Written at time physician decides patient is ready to go home or be transferred to another facility

Clinical Information

Medical Hx
Dx Theraputic Orders

Purpose of Uniform Healthcare Data Sets

Ensure data collection for every patient is consistent
Enables comparison of health care data on a national level for analysis

Interval Note

Info about pt current complaint
Any relevant changes in condition
Physical Findings since last admission

Progress Note

Chronological record of the clinical observations of the pt condition and response to treatment during the hospital stay
Supports medical necessity
Written every 1 to 2 days
The more often the notes are written the better

Flow Charts

Used to document pain assessments, intake/output of fluid in the body in graphic form

Graphic Records

Used to document vital signs

Clinical Protocols

Describe a specific procedure step-by-step
Kept as permanent part of the health record
Facility specific

Case Management

Ongoing review of medical care to ensure the necessity and effectiveness of the services being provided to the patient

Charting By Exception

Document only abnormal/unusual findings, treatment rendered or patient response

Clinical Practice Guidelines

Guidelines which support and standardize clinical decision making for specific medical conditions

Care Plan

A multidisciplinary tool for organizing the diagnostic and therapeutic services to be provided to a patient

Discharge Summary Timeliness

Completed by attending physician within 30 days of discharge

A discharge note may be substituted for a discharge summary when.........

hospitalization < 48hrs for an uncomplicated stay
uncomplicated delivery of an infant (moms record)
normal newborn infant (baby's record)

Autopsy Report Timeliness

Provisional Autopsy Record- within 3 days of autopsy
Final Autopsy Record- within 60 days after completion


number of pregnancies


number of deliveries of viable infants


Venereal Disease Research Lab


discharge of blood from the uterus after birth


placenta and membranes extruded after birth


Emergency Medical Treatment and Active Labor Act
Prohibits the transferring of uninsured patients to public hospitals to avoid treating them

Occupational Therapy

restores pt ability to perform daily activities of living
(self care activities)

Recreational Therapy

restores pt ability to enhance independent living skills through recreational opportunities

Source Oriented Health Records

Documents grouped together according to department they originated, then arranged in chronological (or reverse Chronological) order

Problem Oriented Health Records

Arranged according to a problem list

Problem List

Listing of patients past and present social,psychological, and medical problems.
Each problem indexed with a unique number
Reports/documentation reference the # of the problem they address

4 components of a problem-oriented health record

Problem List
Database (contains CC,present illness,social/med hx,physical exam,test results)
Initial Care Plan
Progress Notes

SOAP notes

Format of progress notes
Subjective (what patient tells Dr)
Objective (what Dr observes)

Medicare Conditions Of Participation

Includes standards for health record content,confidentiality, and retention
Published under the Code Of Federal Regulations (CFR-42)

Federal Register

A daily legal newspaper, which publishes final changes/updates to the Code Of Federal Regulations


State agency gives a facility permission to operate
Ex. OH Dept Health

Deemed Status

If a healthcare organization is accredited by Joint Commission or AOA they are automatically eligible for Medicare/Medicaid reimbursement


Ex. CARF,Joint Commission

Osteopathic Medicine

Focuses on relationship between organs and musculoskeletal system

Timeliness of Delinquent Records according to Joint Commission......

records are considered delinquent if not completed within 30 days after discharge

Pernicious Anemia

Anemia due to Vitamin B12 deficiency

Stage I Decubitus Ulcer

Nonblanchable erythema of intact skin the heralding lesion of skin ulceration. In individuals with darker skin, discoloration, warmth, edema, induration, or hardness may be indicators.

Stage II Decubitus Ulcer

Partial thickness skin loss involving epidermis, dermis, or both. The lesion is superficial and presents clinically as an abrasion, blister, or shallow center.

Stage III Decubitus Ulcer

Full thickness skin loss involving damage or necrosis of subcutaneous tissue that may extend down to, but not through, underlying fascia.

Stage IV Decubitus Ulcer

Full thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures.

Early Fetal Death

Less than 20 weeks gestation or wt of 500g or less

Intermediate Fetal Death

20-less than 28 weeks gestation or a wt of 501-1000g

Late Fetal Death

28 weeks gestation or a wt of more than 1000g

Direct Maternal Death

Death of a woman resulting from OB complications of the pregnancy,labor or puerperium (birth-6 weeks after delivery)

Indirect Maternal Death

Death of a woman from a previously existing disease that developed during pregnancy,labor or the puerperium that was not due to obstetric causes but although the physiologic effects of pregnancy were partially responsible for the death

Joint Commission States that the gross autopsy report be completed in how many days?

3 days

Joint Commission States that the microscopic autopsy report be completed in how many days?

60 days




Middle number
Arrange numbers in numerical order


The value that occurs most frequently


Largest value-Smallest value

How do you get the median in an even number of values?

Add the 2 middle values and divide by 2

If the Standard Deviation is.........there is less dispersion around the mean.


If the Standard Deviation is.........there is more dispersion around the mean.


Normal Distribution of Data

Most values in a set of data are close to the average Relatively few values tend to one extreme or the other, creating a Bell Shaped Curve

Skewed to the right

The longer tail is on the right p 186

Skewed to the left

The longer tail is on the left p 186

Discrete Data

*Can only have specified values
*An exact number/not a fraction
*Ex. Number of children in a family

Continuous Data

*Not restricted to certain specified values
*Can be a fraction
*Ex. Temperature 102.6, Height

Graphs should be greater in...............

length than height

Horizontal Axis is............

left to right
X axis

Average Length of Stay can be calculated as............

Discharge Days/Discharges

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