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72 terms

Health Information Management

Chapter 4 The patient Record Hospital, Physician Office, and Alternate Care Settings
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Alternate Care Facilities
Alternate Cares Facilities that provide behavorial health, home health, hospice, outpatient, skilled nursing, home health, and other forms of care also serve as a documentation source for patient care information
Patient Care Record
serves as the business record for a patient encounter, contains documentation of all healthcare services provided to a patient, and is a repository of information that includes demographic data, as well as documentation to support diangnoses, justify treatment, and record treament result.
Demographic Data
patient identification information that is collected according to facility policy(e.g., patient's name, date of birth, mother's maiden name, and Social Secuirty number).
Information Capture
"The process of recording representations of human thought, perceptions, or actions in documenting patient care, as well as device-generated information that is gathered and/or computed about a patient as part of health care "
Medical Transcriptionist
listens to dictated information and keyboards the report
Medical Transciption
involves a keyboard medical information dictated by a provider.
The owner ship of patient records
The ownership is the property of the provider, and as governed by federal and state laws, the patient has the right to access it contents for review and to request that inaccurate information be amended.
hospital inpatient records
documents the care and treatment received by a pateint admitted to the hospital
Hospital Outpatient or Hospital ambulatory care record
Documents services received by a patient who has not been admitted to the hospital overnight and includes ancillary services, emergency department services, and outpatient surgery.
Auto-Authentication
involves a provider authenticating a dictated report prior to its transcription.
Authentication
an entry is signed by the author
Countersignature
is a form of authentication ny an individual in addition to the signature by the orginal author of an entry.
Telephone Order (T.O)
is a verbal order taken over the telephone by a qualified professional from a physician.
Voice Order or verbal order
is an order where the physician dictates an order in the presence of a responsible person.
signature legend
is a document maintained by the health information department to identify the author by full signature when initials are used to authenticate entries.
Electronic signature
is a generic term that refers to the varous methods by which and electronic doument can be authenticated
Digital signature
which is created using public key cryptography to authenticate a document or message
Public Key Crytography
uses an algorithm of two keys, one for creating the digital signature by transformating datat into a seemingly unintelligible form and the other to verify a digital signature and return the message to its original form
ASTM-1762-Standard Guide for Authentication of Healthcare Information
Is intended to complement standards developed by other organizations
ASTM-1762-Standard Guide for Authentication of Healthcare Information
A document structure for use by eletronic signature mechanisms
The characteristics of an electronic signature process
Minimum requirements for different eletronic signature mechanisms
Signature attributes for use with electronic signature mechacanisms
Acceptable eletronic signature medchanisms and technologies
Minimum requirements for user identification access control, and other security requirements for electronic signatures
Technical details for all electronic signature mechanisms in sufficient detail to allow interoperability between systems supporting the same signature mechanism
Abbreviation List
include medical staff approved abbreviations, acronyms, and symbols that can be documentd in patient records.
Amending the patient Records
correcting documentation in the patient record. The only person authorized to correct an entry is th eauthor of the orginal entry.
audit trail
is a technical control created by an electronic health record system and consist of a listing of all transactions and activities that occured.
Addendum
clarify or avoid incorrect interpretation of informaiton about previous documentation or enter a late entry. The purpose to addendum is to proved addional information, not to change documentation, and the addendum should be documented as soon after the original entry as possible.
Preadmission testing (PAT)
incorporates pateint registration, testing, and other services into one visit prior to inpatient admission, adn the results are incorporated into the patient's record.
provisional diagnosis
( or working, tentative, admission, preliminary diagnoses), which is obtained from the attending physician ad is the diagnosis upon which patient care is based
patient representative
the person who has legal responsbility for the patient signs an admission consent form to document consent to treatment.
nursing assessment
documents the patient's history, current medications, and vital signs on a variety of nursing forms, including nurses notes, graphic charts, and so on.
reverse chronologial data order
means that the most current document is filed first in a section of records
Chronological order
Discharged patients informaiton is the oldest is filed first in a section
solo practioner
a physician who practices alone, are typically not as structerd as records created for group practices
mHealth
refers to the use of wireless technology to devisions while reducing the cost of care and improvingconvenience to caregivers
Signature Stamps
are authorized for use in a facility, the provder whose signature the stamp represent must sign a statement that she or he alone will use the stamp to authenticate documents.
Primary sources
Records that document patient care provided by health care professionals
Incident Report
collects information about a potentially compensable event
potentially compensable event (PCE)
is an accidnet or medical error that results inpersonal injury or loss of property
Source Oriented Record (SOR)
maintains reports according to source of documentation. This means that all documents generated bu the nursing staff are located inn a nursing section of the record, radiology reports in a radiollogy section, and physisican generated in the miedical section.
Problem Oriented Record (POR)
a more systematic method of ducumentation, which consists of found components: Database, Problem list, Initial plan, Progress notes
Data
contains a minimum set of data to be collected on every patient, such as cheif complaint, present conditions and diagnosis; social data; past personal, medical, and social history and baseline labortory data
Diagnostic/management plans
plans to learn more about the patient's condidtion and the management of the condition
Therapeutic plans
specific medications, goals, procedures, therapies, and treatments used to treat the patient
Patient education plans
plans to educate the patient about conditions for which the patient is being treated
SOAP
a structure in a POR, each patient is assigned one or more problems and notes are documented
Subjective (S)
Patient's statement about how she feels, including, symptomatic infomration (e.g headache)
Objective (O)
Observations about the patient, such as physical findings or lab or X-ray results (e.g. chest X-ray negative)
Assessment (A)
judgement, opinion, or evaluational made by health care provider (e.g. acute migraine)
Plan (P)
diagnostic, therapeutic, and educational plans to resolve the problems (e.g. patient to take Tylenol as needed for pain)
archived records or inactive records
Records placed in storage and rarley accessed
Retention period
Those stored in paper format create the need for a large filing area; therefore, each facility should develop policies that indicate the length of time a facility will maintain and archieved record.
Shadow record
a paper record that contains copies of orginal records and is maintained separately from primary records (pg.93)
Independent database
contains clinical infromation created by researchers, typically in academic medical center
Purge
remove inactive records from the file system
statue of limitation
the time period during which a person may bring forth a lawsuit
age of consent
age of majority, which means facilites must retain records for time period (e.g., 18 years) in addition to the retention law.
record retention schedule
This schedule outlines the information that will be maintained, the time period for retention, and the manner in which information will be stored. Records can be stored on paper, microfilm, magnetic tape, optical disk, or as part of an electronic system.
When developing a record retention schedule, consider the following
Accreditation agency recommendations, Federal retention laws, Legal requirements, Need for continuing patient care, research/ education uses, State retention laws
Alternative storage method
off-site storage, microfilm, or optical imaging
Off-site storage or remote storage
is used a to store at a location separate from the facility
Microfilm
is a photographic process that records the original paper record on film, with the film image apperaring similar to a photograph negative (e.g.,the paper record is prepared according to the same method used for scanning)
Aperture card
Punched card onto which frames of a microfilmed document are mounted.
Cartridge film
Roll film that is stored in a plastic cartridge for protection and holds multiple patient records.
Jacket film
Individual images stored in 4X6 inch plastic sleeves, which contain multiple rows per page.
Microfiche film
A 4X6 Mylar film strip that holds thousands of images of multiple patient records.
Roll film
Continuous strip of film that holds thousands of images of mutiple patient records (roll film is often stored on a plastic reel)
Record destruction methods
for paper records usually include dissolving reords in acid incineration, pulping or pukverizing (crush into powder), or shredding
magnetic degaussing
alters magnetic fields on a computer medium
Record Assembly
Process of organizing discharged patient record according to chart order and preparing it for storage
Quantitative Analysis
Review of patient record for completeness, including identification of chart defiencies, which include missing reports and other documentation and missing sinatures.
Deficiency slip
is used to record chart deficiencies that are flagged in the record
Chart deficiencies
include missing reports and other documentation and missing signatures
Concurrent Analysis
Review of patient record for inconssistencies that may identify incomplete or inaccurate documentation, indluing review of final diagnoses or prcedures on the face sheet
Statistical Analysis
Abstracting data from the patient record for clinical or administrative descision making.