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(Sayles chapter 3) health information
functions, purposes and users
The health record - correct answer This contains The Who, what, where, what, and how of patient care and is used for different reasons by many people. Data is raw facts and figures and information is data that has been turned into something meaningful - correct answer What is the difference between the terms data and information Providing care to patients - correct answer What is the primary purpose of the health record Patient care Management of patient care Administrative purposes - correct answer These fall under primary purposes Patient care - correct answer Documentation of the care provided by physicians, nurses, and allied health professionals. Contains treatment and response to treatment. Management of patient care - correct answer Development of patient care standards; they conduct research and evaluate quality of care. Administrative purposes - correct answer Includes billing for services provided; making decisions about future healthcare facility; monitoring fiscal health of organization and staff scheduling Secondary purposes - correct answer Used for many things that is not related specifically to patient care Education of healthcare professionals
Legal, accreditation, and policy development Public health and research - correct answer These fall under secondary purposes EHR is electronic records Paper is paper records Hybrid is both electronic and paper - correct answer What is difference between EHR, paper, and hybrid records Healthcare providers - correct answer Primary users of the health records Aggregate data - correct answer This is data that has been extracted from individual health records and combined to form deidentified information about groups of patients that can be compared and analyzed. An example: this data can be used to determine the survival rates for various kinds of cancer or to determine if a new drug is safe Individual users - correct answer They use the health record in order to complete their jobs Individual users of the health record - correct answer Patient care providers, patient care managers and support staff, coding and billing staff, patients, employers, lawyers, law enforcement officials, healthcare researchers and clinical investigators, and government policy makers are examples of Institutional users - correct answer They need access to the health record to complete their mission Institutional users of the health care - correct answer Healthcare delivery organizations, third-party, medical review organization, research organizations, education organization, accreditation organizations, government licensing agencies, and policy-making bodies are examples of HIM department - correct answer Focusing on ensuring the quality, security, and availability of the health record are functions of the
Overlap - correct answer When a patient has more than one health record number at different locations in an enterprise. To match patients so the patient information can be merged - correct answer What are algorithms used for Deterministic algorithm - correct answer Requires exact matches in data element such as patient name, date of birth, and ssn Probabilistic algorithm - correct answer Uses mathematical probabilities to determine the possibility that two patients are the same Rule-based algorithms - correct answer Assigns weights to specific data elements and uses those weights to compare one record to another Identification systems - correct answer ______ link the patient to the health record. False - correct answer Social security can be used for health record in a healthcare facility Serial numbering system - correct answer A unique numerical identifier for every encounter at the healthcare facility. When a patient is admitted to the healthcare facility five times he or she will have five different health record numbers. Unit numbering system - correct answer Health record number that is issued for the first encounter and used for all subsequent encounters Serial-unit numbering system - correct answer An new issued health record number with each encounter but all the documentation is moved from the last number to the new number
alphabetic filing system - correct answer Used by small clinics and physician offices. The folders are filed alphabetically by patient last name. If more than one patient has the same last name, then first and middle initial is used The unit numbering system - correct answer What is the most common system used in EHR Patient account number - correct answer A number assigned by a healthcare facility for billing purposes that is unique to a particular episode of care; a new number is assigned each time the patient receives care or services at the facility alphabetic filing system and Terminal-digit filing system - correct answer Filing cabinets Shelving units Microfilm Off-site storage Image-based storage - correct answer What are the different options for storing paper records Outguide - correct answer A common way of tracking the location of a health record is the ________. It identifies where the health record is located and when it was removed Requisition - correct answer When a record is needed by a patient care area or other department in the healthcare facility, they submit a ______. Record processing - correct answer Ensures that health records are organized and meet standards. It help ensure the accessibility and completeness of health record Record reconciliation - correct answer What task is done to ensure that all health records have been received.
Clinical forms committee - correct answer Every healthcare facility should have a ______ to establish standards for design and to approve new and revised forms. They should also have oversight of computer screens and other data capture tools. audit trail - correct answer The EHR is able to track who has access to a record through this. It is a chronological set of computerized records that provides evidence of information system activity. (Logins and log outs, file accesses) it is also used to determine security violations. Indexing - correct answer Is the linking of patient name, health record number, document type, and other identification information to the scanned document. An electronic work queue - correct answer What allows the record to be routed to all healthcare professionals who have deficiencies so they are able to access, complete, and authenticate (sign) the health record Version Control - correct answer What must be developed when multiple copies of the same documents are present in the health record. I.e unsigned and signed document, when addendums, corrections, or amendments are made to original documents. Free-text data - correct answer Is unstructured narrative data that is the result of a person typing into an information system. The typist can type anything into this field structured data - correct answer What is the preferred data type structured data - correct answer This is when you point and click or otherwise select the data. For example, having two choices in the gender data field: male or female ... - correct answer Why is the copy and paste function not preferred? What are some of the risks to documentation integrity using the copy and paste function? Digital dictation - correct answer What is a common method to capture dictation in the EHR
Digital dictation - correct answer This is when the physician or other healthcare provider dictates a medical report and the transcriptionists types what is said into an electronic, or digital, format. These reports are electronically transmitted to the EHR where the physician is able to sign the document voice recognition technology - correct answer A computer captures the dictation and converts what is said directly into text and no transcriptionist is needed. The transcriptionist becomes an editor and therefore focuses on data quality natural language processing - correct answer This is the software used for speech recognition. It converts human language (structured or unstructured) into data that can be translated and manipulated by computer Email Voicemail Audio Monitoring strips Images (radiology, pathology) Video (heart catheterization) Monitoring (fetal, electrocardiogram) - correct answer What documentation sources are now featured in the EHR that were not previously in paper records? data mining - correct answer This is the process of extracting and analyzing large volumes of data from a database for the purpose of identifying hidden and sometimes subtle relationships or patterns and using those relationships to predict behaviors. It is used to determine why one physician's outcomes are better or which medication is most effective False. Policies should state who has the right to unlock the document. - correct answer T/F :Once a document is authenticated, the document should be locked in order to prevent changes. In the event that changes, corrections, amendment, or addendums need to be made the document would need to be unlocked. Anyone has the ability to unlock the document.
Ensuring records are available first and foremost for patient care as well as making sure ONLY the REQUESTED documents are submitted - correct answer What do the quality control functions include ROI supervisor - correct answer Who is responsible for ensuring turnaround times are met when a request is made for patient information turnaround time - correct answer This is the time between receipt of request and when the request is sent to the requester The ROI staff - correct answer Who is responsible for documenting to whom they released information, when it was released, and specifically what was released? Clinical coding - correct answer Assigning codes to represent diagnoses and procedures, is a key responsibility of which HIM department Abstracting - correct answer Extracting information from a document to create a brief summary of a patient's illness, treatment, and outcome Abstracting - correct answer The process of extracting elements of data from a source document or database and entering them into an automated system Quality Improvement - correct answer What is this? Billing - correct answer What department is this Registries - correct answer What department is this Chart tracking - correct answer What is this Release of Information (ROI) - correct answer What is this
Encoder - correct answer Assigns diagnosis and procedure codes. This system can query a coder to determine if related codes should be assigned Grouping - correct answer Uses codes assigned to determine the diagnostic related group or other grouping Computer assisted coding - correct answer This uses EHR data to assign the codes. Clinical Decision Support (CDS) - correct answer Assists physicians and other users when making decisions regarding medication, diagnosis, and such based on the information entered into the EHR. The EHR contains alerts and reminders to notify the user of medication allergies, tests that should be performed, immunizations due and so forth Meaningful Use (MU) - correct answer personal health record (PHR) - correct answer
