health care services
The patient record contains documentation of all _________ provided to patient.
demographic data, diagnoses, treatment, treatment results
The patient record is a repository of of information that includes ___________, and documentation to support _________, justify _________, and record ________.
Patient name, date of birth, place of birth, social security number, make up a patient's __________.
name, mailing address, telephone number
The facility must include its _______, _________, and _______ on each page of the patient record.
Process of recording representations of human though, perceptions, or actions in documenting patient care.
Process of analyzing, organizing, and presenting recorded patient information for authentication and inclusion in the patient's healthcare record.
continuity of care
Includes documentation of patient care services so that others who treat the patient have a source of information to base additional care and treatment.
quality of care, third-party payers, medicolegal, patient, facility, providers, research, education, policy-making
Secondary purposes of the record include: evaluating _____; providing information to _________ for reimbursement; serving the _______ interests of _____, ______, and ______; providing data for ______, _______, and ______.
right to access, inaccurate, amended
The patient has the ___________ their record and request that ________ information be ________.
hospital inpatient record
Documents the care and treatment received by a patient admitted to the hospital
The hospital inpatient record documents care and treatment received by a patient ______ to the hospital.
Data that includes all patient health information obtained throughout treatment and care of patient.
Patient name, martial status, place of employment, date of birth, insurance number, and third-party payer are what type of data?
Physical and history, operative records, lab reports, discharge summary, progress notes are what type of data?
hospital outpatient record
Documents services received by a patient who has not been admitted to the hospital overnight.
ancillary, emergency department, outpatient surgery
The hospital outpatient record contains information about ______ services, _______ services, and _________.
The Joint Commission states that only ________ individuals may make entries in the medical record.
federal and state laws, accreditation, professional, legal
Health care providers are responsible for documenting care, treatment, and services in a manner that complies with _________ as well as _______, _______, and _______ standards
patient, third-party payer, refuse to pay
If the provider performs a service, but doesn't document it, the ________ or _________ can ________ for service
author, accurate, verified
CMS specifies that only the _______ of an entry can authenticate that entry, thus establishing that the entry is ____ and has been ______ by the author.
written signatures, countersignatures, initials, fax signatures, electronic signatures, signature stamps
Documents can be authenticated through these six methods:
first initial, last name, title/credential or discipline
At a minimum, the facility must require the providers to sign with their _____, ______, and _________.
Form of authentication by an individual in addition to the original author of entry.
___________ are required when nurses and other authorized personnel document a verbal order from a physician.
Verbal orders, specifically telephone orders, must be authenticated by responsible physician within _____ of documentation.
Document maintained by the health information department to identify the author by full signature when initials are used to authenticate entries.
Refers to various methods by which an electronic document can be authenticated.
Certificates of Medical necessity, durable medical equipment
Medicare does not allow the use of signature stamps on ___________ for ___________.
30, 24 hrs
CoP requires a complete physical exam to be performed no more than _______ days prior to admission or within ______ after admission
CoP requires report of physical exam must be placed in patient record within ______ after admission.
JC requires the H & P to be documented in the patient record within _______ of inpatient admission.
single line, incorrect information, date, time, sign, reason for the error, as close as possible, correct information, as close as possible
To amend the patient record, the provider needs to: draw a _________ through the __________; ______, _____, and ______ the corrected entry; document a _______ in a location _________ to original documentation; enter the __________ in a location ________ to original documentation.
Electronic health records will automatically create a list of all changes made to patient documentation. This is called an:
written statement, disagreeing
If the covered entity denies the request to amend or correct the record, the individual can submit a _______ ________ with the denial.
Method to amend the record that provides additional information about previous documentation. It is also used to enter a late entry.
addendum, clarification, late entry, current date, time, original date, time, authenticate, reason
When adding an addendum, the provider should: document the word _________ or _________ or _______; document the _________ and ________ as well as ______ and ______; ________ the addendum; provide the _________ for the addendum.
If routine review of patient records reveals missing information and hospital staff fill in missing information as the result of an audit, this is considered _____________ of records or ________ with the record and is illegal.
This incorporates patient registration, testing, and other services into one visit prior to inpatient admission and results are incorporated into the patient's record.
demographic information, course of treatment, discharge information
The patient record consists of three major sections. They are:
This is obtained from the attending physician and is the diagnosis upon which patient care is based.
working, tentative, admission, preliminary
Provisional diagnosis is also known as ______, ______, ______, or _______ diagnosis.
This person is responsible for performing an admission history and physical exam on the patient in a hospital.
This person is responsible for dictating a discharge summary to document care provided to patient during inpatient hospitalization.
reason for hospitalization, course of treatment, condition at discharge
A discharge summary includes which three things?
reverse chronological order
Documents are organized from the most current document to least current document.
reverse chronological order, chronological order
Most facilities organize the patient record in _______ during inpatient hospitalization, and ________ once patient is discharged.
universal chart order
When facilities organize reports in same order for both inpatient and discharged patient records, the facility is using a:
Collects information about a potentially compensable event, an accident or medical error that results in personal injury or loss of property.
note, report, patient record
Do not enter a _______ in the record that an incident report has been completed. Do not file an incident _____ in the _________.
source oriented record
Type of patient record format that organizes information according to source of documentation.
hard to follow
A disadvantage of a source oriented record is that its _________ a particular diagnosis.
problem oriented record
Type of patient record format that more systematic and consists of four components
database, problem list, initial plan, progress notes
The problem oriented record consists of what four sections?
In a problem oriented record, this contains a minimum set of data such as chief complaint, conditions and diagnoses, social data, history, physical exam, and baseline lab data.
In a problem oriented record, this contains the strategy for management of the patient's care and describes actions that will be taken to learn about patient's condition and treat/educate patient.
strategy for management, action, learn, treat/educate
In a problem oriented record, the initial plan contains the _____ of the patient's care and describes _____ that will be taken to _____ about patient's condition and ______ patient.
diagnostic/management, therapeutic, patient education
The initial plan in POR contains these three types of plans.
In the problem oriented record, problems and notes are documented using the _________ structure.
In the POR, this section of the progress notes provides the patient's statement about how she feels, including symptomatic information.
In the POR, this section of the progress notes provides observations about the patient including physical findings or lab/x-ray results.
In the POR, this section of the progress notes provides judgment, opinion, or evaluation made by health care provider.
In the POR, this section of the progress notes provides diagnostic, therapeutic, and educational solutions to resolve the problems.
Type of patient record format that usually arranges reports in strict chronological date order.
This type of patient record allows for observation of how patient is progressing according to test results and how patient responds to treatment.
organized, easy to use, time-consuming
Advantages of the integrated record are that it is highly _____, ______, and less ______.
With integrated records, typically it is difficult to ______ and _____ information.
A storage solution that consolidates electronic records on a computer server for management or retrieval.
Paper record that contains copies of original records and is maintained separately from the primary record.
CoP requires hospitals, long term care facilities, specialized providers and home health agencies to retain records for a period of no less than _______.
statute of limitations, age of consent
Some states establish time frames for record retention based on _________ and __________.
age of consent
States that govern the __________ require facilities to retain records for a time period in addition to the retention law.
10 years, permanently
AHIMA recommends that operative indices be retained for a minimum of _______ and the operating room register _________.
record retention schedule
Outlines the information that will be maintained, the time period for retention, and manner in which information will be stored.
maintained, time period, manner
The record retention schedule outline the information that will be ______, the _______ for retention, and _______ in which the information will be stored.
accreditation agency, federal and state, legal, research/educational
Record retention schedules should be established based on: ______ recommendation, _______ laws, _______ requirements, _______ uses.
cost, storage, transportation, security, access
What are five considerations when selecting an off-site storage facility?
certificate of destruction
After destruction, a ______________ is produced and permanently maintained.
date, method, supervisor, destroyed records, disposal, normal course of business
A certificate of destruction should have a ______ and _____ of destruction, signature of ______, listing of _________, dates of ________, and __________.
notified, closure, new location
When a facility closes, patients must be _______ of _______ and ________ of records.
part of the sale
When a facility is sold to another health care entity, records are considered _______.
This group is responsible for ensuring high quality medical care and that care is documented as part of a complete and accurate record.
This group is responsible for ensuring that the medical staff adopts rules and regulations for maintaining records and enforcing medical record policies.
high quality, complete, accurate
The governing body is responsible for ensuring _______ medical care and that care is documented as part of a __________ and _______ record.
medical staff, medical record
The facility administration is responsible for ensuring that the ________ adopts rules and regulations for maintaining records, and enforcing __________ policies
health information manager
This person is responsible for educating physicians/health care providers about proper documentation procedures and policies.
health information staff
These people assist in design of patient record systems to facilitate sound record documentation practices and performs record completion tasks.
This involves organizing discharged patient records according to accepted chart order and preparing for storage.
organized, chart order, storage
In record assembly patient records are _______ according to accepted ________ and prepared for ________.
This involves the review of the patient record for completeness, and identification of chart deficiencies.
In quantitative analysis, the record is reviewed for _______ and _______________.
This involves the review of the patient record for inconsistencies that may identify incomplete or inaccurate documentation.
inconsistencies, incomplete, inaccurate
In qualitative analysis, the record is reviewed for _________ that may identify ________ or _______ documentation.
This involves the review of the patient record during inpatient hospitalization to ensure quality care through quality of documentation.
inpatient hospitalization, quality care, quality of documentation
In concurrent analysis, the record is reviewed during ____________ to ensure _________ through _________.
This involves abstracting data from patient record for clinical/administration decision-making.
abstracted, clinical/administration decision-making
In statistical analysis, data is ________ from patient record for _____________.
diagnosis, care, treatment, services provided
The primary purpose of the patient record is to support and justify the patient's ______, _____, _____, and ______.
course of treatment, results
The primary purpose of the patient record is to document the _______ and ______.