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12 terms

DATA NEEDS/AMBULATORY CARE

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ambulatory or outpatient care
patients arrive for treatment and leave after treatment is administered; they do not stay overnight
hospital-based
free standing
what are two principal categories of ambulatory care
hospital based ambulatory care
emergency department
hospital clinic
same-day surgery center
partial hospitalization program
ancillary services such as lab or x-ray
observation services(less than 24 hours)
free standing ambulatory care
physician office
university health centers
neighborhood health centers
ambulatory surgery centers
urgent care centers
birthing centers
renal dialysis centers
uniform care ambulatory data sets(UCADs)
data elements for emergency department systems (DEEDS)
what are data sets for ambulatory care providers
Uniform ambulatory care data set(UACDS)
1)approved by the NCVHS in 1989
2)includes segments that describe the patient, the provider, and the encounter
data elements for emergency department systems(DEEDS)
uniform specifications for data entered in ED patient records to reduce incompatibilities in ED records
DEEDS
patient identification data
facility and practitioner ID data
ED payment data
ED arrival and first assessment data
ED history and physical examination
ED procedure and results data
ED medication data
ED disposition and diagnosis data
centers for medicare and medicaid services
accreditation association for ambulatory health care
joint commission
commission on the accreditation birth center
what are examples of accreditation/certification agencies
unique health record requirements
1)ambulatory surgery centers must assure that each patient is evaluated by a physician or an anesthetist for proper recovery before discharge from the center
2)ambulatory surgery center provides each patient with written discharge instructions and overnight supplies
3)problem list
UHR requirements for medicare
certified ambulatory surgery centers, results of any preoperative diagnostic studies performed are entered into the medical record before surgery to evaluate the risk of anesthesia
emergency provisions available to operating rooms must include
emergency call system
oxygen
mechanical ventilator assistance
cardiac defibrillator and monitoring equipment
a trach set
laryngoscopes and endotracheal tubes
suction equipment