HIM 101 Final

State Licensure

"process by which a governmental authority grants permission to an individual practitioner or healthcare organization to operate or to engage in an occupation or profession"

examples of policies regarding amending, correcting, or deleting health record entries

- After a document or entry in a health record has a final signature on it, the only way to correct it is to add an addendum to the record. The addendum must have a separate signature, date, and time from the original entry. -The original version of the document in a corrected health record must be maintained. The version should be clearly indicated on the document. EX: reports should indicate, "Final Copy", "Preliminary Copy", or "final copy with corrections." -A health record should be locked from editing once the final signature has been applied. - The appearance of information added to the record to amend or correct it should be different than the original entry (that is, it may be a different color, italic, or bolded).

Features of Navigation design:

- All controls should be clear and placed in an intuitive location on the screen - Use neutral colors and limit highlighting, flashing, and so forth to reduce eye fatigue - Limit choices and label commands -Provide undo buttons to make mistakes easy to override - Use consistent grammar and terminology - Provide a confirmation message for any critical function (such as deleting a file)

Functional Components of HIM Core Model (6)

- Data Capture, Validation, and Maintenance - Data/Information, Analysis, Transformation, and Decision Support -Health Information Resource Management and Innovation - Information Governance and Stewardship - Quality and Patient Safety

Features of Output design

- Minimize the number of clicks needed to reach data or a specific screen - Combine data into a single, organized menu to eliminate layers of screens. The system should also mark required data fields so that the EHR user cannot proceed to the next screen without completing required information.

Features of Data validation

- Perform a completeness check to ensure that all required data have be entered - Perform a format check to ensure that data are the right type (Numeric, alphabetic, and so on) - Perform a range check to ensure that numeric data are in the correct range. - Perform a consistency check to ensure that combinations of data are correct - Perform a database check to compare data against a database or file to ensure data are correct as entered.

EHR selection features

- Screen Design -Navigation Design - Input Design -Data validation -Output Design

Features of Input design:

- Simplify data collection - Sequence data input to follow workflow - Provide a title for each screen - Minimize keystrokes by using pop-up menus - Use text boxes to enter text - Use a number box to enter numbers - Use a selection box to allow the user to select a value from a predefined list: check boxes (multiple selections), radio buttons (single selections), on-screen list boxes (drop down list boxes or combo boxes)

Monitoring Quality Control of Medical Transcriptions

- To monitor transcription accuracy, a sample of the transcriptionists' reports can be checked for wrong terms, misspelled words, incorrect format, and/or grammatical errors. The number of errors found is noted, and an error or accuracy rate is determined and compared against an established standard. - Transcription turnaround time also can be monitored to determine whether reports are being transcribed within the expected time frame set in a standard. Most dictation/transcription computer management systems track the date and time reports are dictated and transcribed. A report indicating dictation and transcription time and date can be used to determine turnaround time.

Minimal amount of data required for a disease or operation index includes: (8)

- principal diagnosis and relevant secondary diagnosis - associated procedures - patient's health record number -patient's gender, age, and race - attending physician's code or name - the hospital service - the end result of hospitalization - dates of encounter (including admission and discharge for inpatients)

Capture of EHR data:

-Data are entered directly into the computer at the point of care - Paper documents are scanned and imaged -Other computer systems are interfaced with the EHR (laboratory, radiology) -Transcribed reports are electronically transmitted to the EHR

New roles most likely to evolve with technology

-HIM manager would have enterprise or facility wide responsibility for HIM. -Clinical Data Specialist perform data management functions in a variety of application areas including clinical coding, outcomes management, specialty registries, and research databases. -Patient Information Coordinator: perform new service roles that help consumers manage their personal health information, including personal health history management, ROI, managed care services, and information resources. -Data Quality Manager: perform functions involving formalized continuous quality improvement for data integrity throughout the enterprise -Data Resource Admin: responsible for the net generation of records and data management using media such as the CPR, data repository, and electronic warehousing. -Research and Decision Support Analyst: support senior management with information for decision making and strategy development. - Security Officer - manage the security of all electronically maintained information, including the promulgation of security requirements, policies and privilege systems and performance audits.

What are some specific risks to documentation integrity when using copy functionality?

-Inaccurate or outdated information that may adversely impact patient care, - Inability to identify the author or what they thought. - Inability to identify when the documentation was created. - Inability to accurately support or defend E/M codes for professional or technical billing notes. - Propagation of false information. - Internally inconsistent progress notes

Supervisory responsibilities associated with the management of the HIM functions

-Policy and Procedure Development: the foundation for management and supervision of employees in any dept. Policies are statements that describe general guidelines that direct behavior or direct and constrain decision making in the organization. Procedures are specific statements about how work is to be carried out. Step by step instructions on how to complete a specific task.

ARRA of 2009 - attributes

-Pres Obama -provides funds to promote the use of interoperable, certified health information technologies including EHR adoption. -provides financial assistance and incentives necessary for the transition to electronic health records. Beyond funding, the Office of the National Coordinator for Health Information Technology (ONC) a federal entity located within the Office of the Secretary for the US Department of Health and Human Services (HHS) ESTABLISHED THE STANDARDS.

Work Flow of digital dictation

1 physician dictates a medical report and the transcriptionist transcribes the dictation into a structured medical report. 2. The transcribed reports are electronically transmitted to the EHR. The EDMS attaches an auto-signature deficiency and the transcribed report is then electronically routed to a physician work queue for signature.

Steps for ROI (generally)

1. Enter the request in the ROI database: information such as patient name, date of birth, health record number, name of requester, address of requester, telephone number of requester, purpose of the request, and specific health record information requested is entered in the computer. 2. Validity of the authorization is determined: The HIM professional will compare the authorization form signed by the patient with the facility's requirements for authorization to determine the validity of the authorization form. The facility's requirements are based on federal and state regulations. Certain types of information such as substance abuse treatment records, behavioral records, and HIV records require specific components be included in the authorization form per state (varies per state) and federal regulations. If the authorization is determined to be invalid, the request is returned to the requester with an explanation as to why the request has been returned. If valid to next step. 3. Verify the patient's identity: HIM professional must first verify that the patient has been a patient at the facility. Verification is done by comparing the information on the authorization with information in the master patient index (MPI). The patient's name, date of birth, social security number, address, and phone number are used to verify the identity of the patient whose record is requested. Patient's signature in the health record is compared with the patient's signature on the authorization for release of information form. 4. Process the request: the record is retrieved and the only information authorized for release is copied and released.

Some HIM functions that include review and analysis of the health record are in place to monitor the healthcare facility's compliance with The Joint Commission standards and include:

1. Record completion process: - monitoring delinquency rates. TJC has a Hospital Medical Record Statistics form which is used by most hospitals to monitor compliance with TJC's standards. -Monitoring timely completion of medical reports: - Monitoring health record completion: document authentication 2. Documentation: - Monitoring the use of abbreviations acronyms, and symbols 3. Confidentiality of information: -Monitoring access to protected health information after discharge 4, Access to patient records: - Storage and retrieval processes accessible for patient care.

EHR Certification requirement by the CMS

1. access control 2. authentication 3. Authorization

Standardization of Medical Practice

1876 - American Association of Medical Colleges (AAMC) standardized the curriculum for US medical schools and help develop the public understanding for the need for licensure of physicians. 1874 American Medical Asso. (AMA) - also worked towards creating state license boards for physicians.

Abraham Flexner

1906 - took on the task to review every medical college in the country for the Carnegie Foundation.

American College of Surgeons (ACS)

1918 - Implemented the hospital standardization program to raise standards of surgery by establishing min. quality standards for hospitals. Recognized that one of the most important items in the care of any patient was a complete and accurate report of care and treatment provided during hospitalization.

Formal Education and Certification

1932 - ARNLA adopted a formal curriculum - they understood the need for preliminary training to be recognized as a profession. First schools for medical record librarians were approved in 1934. By 1941, 10 schools had been approved. This formal accreditation process was the precursor to CAHIIM.

American Medical Record Association (AMRA)

1970 - AAMRL changed their name to AMRA and dropped Liberian from the title - again to reflect changes in the profession. Administrator better mirrored the work performed by members more accurately then librarian.

American Health Information Management Assoc. (AHIMA)

1991 - Name changed from AMRA to AHIMA - Assoc. leaders believed that the management of information rather than the management of records would be the primary function.

Which of the following paper weights would be the most durable for the medical record folder?

20

What would be the linear filing inch capacity for a shelving unit with 6 shelves, each measuring 36 inches?

216 inches

Average Length of Stay (ALOS)

30 days or less

Organization of the Assoc. of Record Librarians

35 members of the club of record clerks met at the Hospital Standardization Conference in 1928 and formed the Assoc. of Record Librarians.

What should be done when the HIM department's error or accuracy rate is deemed unacceptable?

A corrective action should be taken

Peer Review

A member of a profession assesses the work of colleagues within that same profession. Peer Review is both a requirement of CMS and Joint Commission.

Hybrid record

A mix between electronic and paper.

What is overlay?

A patient is assigned another patient's medical record number comingling the medical information of both patient's resulting in problems in identifying what medical information belongs to which patient

Voluntary Accreditation

A system on institutional or organizational review performed by an independent body; Joint commission is a private, non-profit organization that establishes guidelines and standards for the operation and management of healthcare facilities to ensure quality and safety of care; operates voluntary accreditation programs for hospitals etc.

Structure of AHIMA

AHIMA structure is split into two different components: the volunteer component and the staff component.

National Committees

AHIMA's president appoints the members of the assoc. national committees practice councils and workgroups. These groups support the mission of the organization and work on work on specific projects as designated by the president and BOD.

American Assoc. of Medical Record Librarians (AAMRL)

ARNLA changed their name to AAMRL in 1944 to remain consistent with the change in the profession.

Process that determines who is authorized to access patient information in the health record.

Access control: involves determining which individuals or groups should be granted access, what portions of the health record should be available and what right should be granted. Access cards are often used in combination with passwords or personal identification numbers (PINS) as a method of authenticating identity

NCQA (National Committee for Quality Insurance)

Accredits managed care organizations. Focuses on patient safety, confidentiality, consumer protection, access to services.

CARF (Commission on Accreditation of Rehabilitation Facilities)

Accredits rehabilitation programs and services in medical rehabilitation, elderly rehabilitation, behavioral health, children and youth services, employment and community services.

Quality Charateristics

Accuracy; Accessibility; Comprehensiveness; Consistency; Currency; Definition; Granularity; Precision; Relevancy; Timeliness

Types of Medical Staff Classification

Active, provisional, honorary, consulting, courtesy, and medical resident assignments

Health Insurance Portability and Accountability Act of 1996

Addressed issues related to portability of health insurance after leaving employment, establishing national standards for EHR and national identifiers for providers, health plans and employers.

Minimum Standards

Adoption of the Minimum Standards was the basis of the Hospital Standardization Program and marked the beginning of the modern accreditation process for healthcare organizations.

Which of the following should be part of a comprehensive MPI maintenance program?

Advanced Person Search

Clinical Privilege

Aggregate of physicians who have been granted permission to provide clinical services in the hospital - limited to the scope of practice

AHIMA Code of Ethics

All members of AHIMA are expected to act in an ethical manner and comply with all laws, regulations, and standards governing the practice of health information management.

The future role of the HIM professional is expected to change due to: a. Advances in technology b. Implementation of new clinical coding system c. Evolution of the EHR d. All of the above

All of these

Which identification system is at a disadvantage when there are two patients with the same name?

Alphabetic

The master patient index (MPI) is necessary to locate health records within the paper-based storage system for all the types of filing systems, except:

Alphabetical

Public Law 89-97 of 1965

Amendment to SS act. Medicare for the people 65+, Medicaid for the poor; Medicare expanded to include - Those willing to pay a premium, Disabled and those with chronic kidney disease. Medicaid expanded: Poor Children, Disabled, Pregnant Women, Very Poor Adults

Reviewing a health record for missing signatures and missing medical reports is called

Analysis

National Patient Safety Goals

Annually addresses specific patient safety concerns.

Student Membership

Any student whom does not carry a AHIMA credential, who has not previously been an active member, and is formally enrolled in a CAHIIM/AHIMA health information management program.

Quality Improvement

Appropriateness (the right care is provided at the right time); Technical Excellence (care is provided in the right manner); Accessibility (care can be obtained when needed); Acceptability (patients are satisfied)

"Loose" reports are health record forms that:

Are received by the HIM department and added to the health record after it has been processed.

Integrated Health Record

Arranged so documentation from various sources is intermingled and follows strict chronological order

EHR reconciliation processes

As with paper-based and hybrid records, electronic health records require that the HIM professional verify that there is an EHR present in the system for every discharged patient and verification of reports.

In a paper-based system, individual health records are organized in a pre-established order. This process is called

Assembly

Which of the following chart-processing activities is eliminated with an EDMS that uses scanned images of barcoded forms? Chart preparation, Scanning, Assembly, Quality review

Assembly

Implied consent

Assumed when a patient voluntarily submits to treatment.

Which term verifies claim of identity?

Authentication

Right or permission given to an individual to use a computer resource or to use specific applications and access specific data; is also a set of actions that gives permission to an individual to perform specific functions such as view, write, edit, delete, or execute tasks

Authorization - authorization software referred to as access control matrix.

Hospital Survey and Construction Act (Hill Burton Act) of 1946

Authorized grants to build new hospitals and modernize old ones; goal of 4.5 beds per 1000 people; As people began to live longer, receive better care and technological advances acute care hospitals began to decline.

Resident Assessment Instrument (RAI)

Based on Min. Data Set (MDS) for long term care - includes MDS, triggers, utilization guidelines, and care area assessments (CAA's). Patient is evaluated and reevaluated at defined intervals as well as when there is a major change in condition.

Six House Teams

Best Practices and standards; Environmental scan; HIM higher education and workforce; House of operations; Professional Development and recognition; Volunteer and Leadership developmental

What department within the hospital uses the information abstracted and coded by the HIM department to send for payment from third-party payers?

Billing Department

Pediatric Documentation

Birth history, nutritional history, personal, social and family history, growth and developmental record and immunizations.

Which of the following is true about the Social Security Number?

Both AHIMA and the Social Security Administration oppose using the Social Security number as the health record identifier

Which of the following is not true of good forms design for paper forms? a. Every form should have a unique identification number. b. Every form should have a clear, concise title. c. Bright colors should be used to identify forms. d. Paper ranging from twenty to twenty-four pounds in weight should be used for forms that will be copied, faxed, or scanned.

Bright colors should be used to identify forms.

Medical Staff Bylaws

Bylaws spell out the specific qualifications that physicians must demonstrate before they can practice medicine in the hospital

Executive Team

CFO - Chief Financial Officer; COO - Chief Operating Officer; CIO - Chief Information Officer;

Certification Standards

CMS - Conditions of Participations for medicare. Reimbursement standards that are applied to facilities that choose to participate in federal programs.

Policy Making Bodies

CMS is responsible for administering the federal Medicare program and the federal portion of the medicaid program. Data taken from medical records and supplied by organizations as part of medicare billing is kept in a national database. The database is used to make decisions related to healthcare reimbursement mechanisms, the effectiveness of healthcare services and the general health of the medicare population.

What are the regulatory agencies regarding legal health records?

CMS, federal regulations, state laws, and standards of accrediting agencies such as the Joint Commission, as well as the policies of the healthcare providers set the standards.

Staff Component

Carries out the operational tasks necessary to support the organizations mission and goals set by the volunteer component

CCHIIM (Commission on Certification for Health Informatics and Information Management)

Certification board - provides the baseline by which to measure qualified HIM professionals, criteria for eligibility for registration, develops and administers the exam.

Which system records the location of health records removed from the filing system and documents the return of the health records? a. Chart deficiency system b. Chart tracking system c. Abstracting system d. None of the above

Chart tracking system

Which of the following is not usually a part of quantitative analysis review? a. Checking that all forms contain the patient's name and health record number b. Checking that all forms and reports are present c. Checking that every word in the record is spelled correctly d. Checking that reports requiring authentication have signatures

Checking that every word in the record is spelled correctly

CNO

Chief Nursing Officer - A registered nurse qualified by advanced education and clinical and management experience usually administers patient care services.

Assigning ICD-9-CM and CPT codes to the diagnosis and procedures documented in the medical record is called:

Clinical coding

Administrative Data

Collected by hospital personal - made up of demographic, social and financial information.

What feature of the filing folder helps locate misfiles within the paper-based filing system?

Color coding

Hybrid Record

Combination of both electronic and paper records.

What is compliance documentation?

Compliance documentation includes all records necessary to protect the integrity of the compliance process and confirm the effectiveness of the program, including employee training documentation, reports from hotlines, results of internal investigations, results of auditing and monitoring, modifications to the compliance program, and self-disclosures. The documentation should be retained according to applicable federal and state law and regulations and must be maintained for a sufficient length of time to ensure its availability to prove compliance with laws and regulations The organizations legal counsel should be consulted regarding the retention of compliance documentation.

State and Local Assoc.

Component state assoc. provide their members with local access to professional education, networking and representation.

Pharmacy

Compounding and dispensing medications, as well as modern services such as reviewing medications for safety and efficiency.

Order-Entry/Order Management

Computerized provider order-entry systems have been developed to improve quality care.

A quantitative review of the health record for missing reports and signatures that occurs when the patient is in the hospital is referred to as a _______ review.

Concurrent

Medicare Conditions of Participation

Conditions that must be met in order to receive reimbursement from Medicare and Medicaid. Joint commission and the AOA are deemed to be in compliance with the conditions of participation and do not have to undergo a separate certification process. 2009 DNV Healthcare Inc was also granted authority by CMS.

CAHIIM (Commission on Accreditation for Health Informatics and Information Management)

Conduct the formal accreditation process of academic programs for AHIMA.

Evidence Based Medicine

Conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients

Medical Staff

Consists of physicians who have received extensive training in various medical disciplines ex: pediatrics, internal medicine

Which of the following is a risk of copying and pasting?

Copying the note in the wrong patient's record.

First Hospitals

Created by religious organizations in medieval Europe to provide care and respite for pilgrims

American Medical Association (AMA)

Created for Physicians and Med Students; Mission: To become world leader in obtaining, synthesizing, integrating, and disseminating information on health and medical practice; To continue to be an authoritative voice and influential advocate for patients and physicians; Important Facts: Publishes Current Procedural Terminology (CPT) coding system. CPT Codes are the basis for reimbursement systems for physicians services and other types of healthcare services provided on an ambulatory basis

Physical Therapy and Rehab

Credentialed Allied Health professionals administer physical therapy under the direction of the physician; objective is to eliminate the patient's disability or alleviate it as fully as possible.

Five main functions for HIM professionals

Data capture, validation, and maintenance; Data/information analysis, transformation and decision support; Information dissemination and liaison; Health information management and innovation; Information governance and stewardship.

data relevancy

Data in the health record has to be useful.

Data Accessibility

Data is easily obtainable. Factors affecting accessibility: previous health records are available; dictation equipment is accessible and working properly; accurate transcription; computer data entry devices are working properly and are readily available; computers and servers are working correctly.

Destruction documentation:

Date of destruction Method of destruction Description of the disposed records Inclusive dates covered A statement that the records were destroyed in the normal course of business The signatures of the individuals supervising and witnessing the destruction

CCHIIM (commission on Certification for Health Informatics and Information Management)

Dedicated to assuring the competency of professionals practicing HIIM. Serves the public by establishing, implementing and enforcing standards and procedures for certification and recertification of HIIM professionals.

DNV (Det Norske Veritas)

Deemed Status. International accrediting organization. Newest accreditation agency

A health record with deficiencies that is not complete within the timeframe specified in the medical staff rules and regulations is called a(n) _________ record.

Delinquent

Public Health Services

Dept. of Health and Human Services is the fed agency that ensures health and provides essential human services; All HHS agencies have some responsibility for prevention; through 10 offices - it coordinates closely with state and local gov. agencies and HHS-funded services are provided by these agencies as well as by private-sector and nonprofit organizations.

Sentinel Event Policy

Designed to identify and prevent the occurrence of events that lead to unexpected deaths or events leading to or potentially leading to serious physical injuries. When an event occurs a root cause analysis and identification of improvements to risks must be undertaken.

AHIMA's recommended destruction standards:

Destroy the records so there is no possibility of reconstruction of information. Paper - burning, shredding, pulping and pulverizing. Microfilm or microfiche- recycling and pulverizing. Laser disks- pulverizing electronic Data- magnetic degaussing leaving the domains in random patterns with no preference to orientation, rendering previous data unrecoverable. Total data destruction does not occur until the original data and all backup information have been destroyed. Magnetic tapes - degaussing

What type of algorithm(s) may be used to identify duplicate medical record numbers?

Deterministic, Probabilistic, and Rules Based.

Diagnostic Medical Sonography/Imaging Tech.

Diagnostic imaging - services provided by physician specialists and technologists including radiation therapists, ultrasound tech's, magnetic resonance tech's.

Where does free-text data exist in the health record?

Dictated and transcribed medical reports are an example. Many advantages of manipulation of data that the EHR offers are lost when the health record is comprised of large amounts of unstructured data.

Dietetics and Nutrition

Dietitian's trained in nutrition. Provide nutritional care to individuals and overseeing nutrition and food settings ranging from hospitals to schools.

Hospice Care

Documentation of a care plan review is required every 30 days.

Source Orientated Health Record

Documents are grouped together according to their point of origin - labs grouped together, radiology etc

Medical History

Documents the patients current complaints and symptoms and lists past medical history and family history.

Clinical Data

Documents the patients medical condition, diagnoses, and procedures performed.

Rise and Fall of hospitals

Due to medical advances and cost-containment measures enabled services that were once inpatient services to be performed on an outpatient bases. Decreased the need for hospitals.

John Smith, treated as a patient at a multi-hospital system, has three medical record numbers. The term used to describe multiple health record numbers is:

Duplicates

Emergency Medical Technology (EMT)

EMT ( Technicians) and Paramedics provide a wide range of services on an emergency basis for care of traumatic injury and other emergency situations and in the transport of emergency patients to a medical facility.

American Academy of Prof. Coders

Educates and certifies medical coders. Sponsor certifications in coding, medical compliance and medical auditing.

Clinical Decision Support

Effective and efficient patient care requires a great deal of complex information. To be an effective tool in clinical decision support, the health record needs to be more than a simple repository of patient care data. Fully functional EHR systems provide a number of decision-making tools that are not currently available in paper-based health record systems.

EHR Systems

Electronic Health Record Systems - electronic collection, storage, and analysis of healthcare information created and maintained in interactive systems. EHR's systems are designed for use by healthcare providers and support the legal mandate providers have to document care.

Specific performance expectations and/or structures and processes that provide detailed information for each Joint Commission standard are called:

Elements of Performance

Others

Employers, Accreditors, Government Policy makers and legislation, Lawyers, Healthcare researchers and clinical investigators; health sciences journalists and editors.

AAAHC (American Association for Ambulatory Health)

Establishes Ambulatory care core standards for Ambulatory care facilities.

Volunteer Component

Establishes the organizations mission and goals, develops policy, and provides oversight for the organizations operations

Physical Therapy

Evaluate and treat patients to improve mobility, reduce pain, maintain cardiopulmonary function and limit disabilities. PTA's carry out the physical therapy plan created by the PT

Basic Documentation Principles

Every healthcare organization should have policies that ensure the uniformity of both the content and the format of the health record; health record should be organized systematically in order to facilitate data retrieval and compilation; only authorized by the organization policies should be allowed to enter documentation in the health record.

True or False: Authorization is identifying a patient through the use of a user name

False

True or False: Data validation includes an undo button

False

True or false In a paper-based record, errors should be completely obliterated

False

Home Care

Fastest growing sector; offers services for Medicare recipients; third-party payers want patients released from Hospital more quickly.

Medicare

Federal Health Insurance for the aged

History of Nursing

First school for nurses was opened in New England for women and children in 1872.

Assoc. for healthcare documentation integrity

Formally American Academy of Medical Transcriptionists - this is an organization dedicated to the capture of health data and documentation.

Can free-text data be easily located, retrieved, and manipulated by a search engine?

Free-text data is undefined, unlimited, and unstructured. It is more difficult for a search engine to find, retrieve, and manipulate its data than structured text.

Indian Health Service

Funded by HHS - provides care to American Indians and Alaskan Natives living on and off reservations

Type of Ownership

Government Owned Hospitals: VA Hospital; Proprietary Hospitals: Owned by private foundations, partnerships, or investor owned corporations; Voluntary Hospitals: Owned by universities, churches, charities, religious orders, unions and other not-for-profit entities.

Health Information Management

HIM Professionals oversee health record systems and mange health-related information to ensure that it meets relevant medical, administrative, and legal requirements.

What is a Loose report?

HIM departments often receive reports belonging to a health record that has already been assembled or scanned. These unprocessed reports are called loose reports or loose filing.

Monitoring of Accreditation, licensure, and standards requirements

HIM director should establish a mechanism that targets specific regulatory or standards groups and monitors for compliance with these standards

Joint Commission Standards and elements of performance

HIM professional must consult the Comprehensive Accreditation Manual for Hospitals published by TJC for a complete listing of standards and elements of performance. The health records review process is a multidisciplinary process coordinated by the HIM dept.

Protected Health Information (PHI)

HIPAA requires that healthcare facilities maintain an account of each required disclosure type of protected health information PHI.

Characteristics of a Hospital

Has an organized medical staff; provides permanent inpatient beds; offers around-the-clock nursing services; provides diagnostic and therapeutic services

Efficiency

Has improved with the with the use of the electronic health record. Providers can easily access information, from one place and there is less risk of the record being misplaced or lost.

Quality improvement programs

Have been in place for years and have been required by medicare/medicaid programs and accreditation standards

Results Management

Having timely access to all types of results, including laboratory results, radiology results, and other test results, over a period of time helps providers make informed choices for diagnoses and treatment and increases quality care.

Describe the electronic sharing of Information among two or more entities.

Health Information Exchange

HIE

Health Information Exchange= the sharing of health information electronically among two or more entities and also an organization that provides services to accomplish this information exchange.

American Recovery and Reinvestment Act 2009

Health Information Technology for Economic and Clinical Health (HITECH) Act - Nationwide health information exchange, use of health information, implementation of electronic health records; Gov involvement in standard development for exchange of health information; Strengthened privacy and security standards; made office of the National Coordinator for health info. tech a permanent office.

Tricare

Health Insurance for retired members of the military and the dependents of active duty and retired members of the seven armed forces.

Allied Health Professionals

Health Professionals who have received a certificate, associates degree, bachelor's, master's, doctorate or post doctoral training in a healthcare related science.

Different levels of care in IDS

Health Promotion and disease prevention; Primary care; Acute care; Tertiary Care; Long-term care and hospice care

Electronic Health Record Core Capabilities

Health information and data - patient data using defined data sets and interfaces with related medical treatment and diagnostic reporting systems; Results management - electronic reporting of tests, consultation, and related patient consents; Order entry and management - electronic order entry with allergy, interaction, and laboratory report interfaces; Decision support - reminders, prompts, diagnoses and disease; Electronic communication and connectivity - exchange of healthcare data across providers within and outside a care setting to support continuity; Patient support - patient education; Administrative processes - electronic scheduling, billing and claims management; Reporting and population health management - quality management and regulatory reporting.

Patient Protection and Affordable Care Act

Health insurance market reforms; exchanges; expansion of medicaid; individual mandates; tax credits for small employers

Optometry

Health profession that is focused on the eyes and related structures.

EHR (Electronic Health Record)

Health record available electronically.

Flexibility

Health record data should be flexible enough to meet the needs of all the records different users. Standardized forms are designed to made data readily available and meaningful to those caring for patients

Patient Care Delivery

Health record documents the services provided by clinical professionals and allied health professionals. Ex. document services; proof of identity; self-mange care, verify billing. Foster continuity of care, document risk factors, decision making about diagnoses.

Which of the following is used to locate an electronic health record

Health record number

AOA (American Osteopathic Association)

Healthcare Facilities Accreditation program accredits acute, speciality, and critical access hospitals; clinical labs, office based surgery and ambulatory care. Deemed status

Educational Organizations

Healthcare professionals undergo rigorous professional education based on classroom and hands on training.

Managed Care

Healthcare reimbursement system that manages cost, quality and access to services; control costs primarily by presetting payment amounts and restricting patient access to healthcare services through precertification and utilization review process.

Long-Term Care

Healthcare rendered in a nonacute care facility to patients who require inpatient nursing and related services for more than 30 consecutive days

One of the advantages of an EDMS is that it can:

Help manage work tasks

Outcomes and Assessment Information (OASIS)

Home Health - OASIS items are a component of the comprehensive assessment that is the foundation for the plan of care, for medicare, reimbursement. Completed every 60 days and with a significant change of condition

Hospital-based Ambulatory Care

Hospitals that provide care on an outpatient bases.

Number of Beds

Hospitals with fewer than 100 beds considered small. Number of beds is broken down by adult beds and pediatric beds

Joint Commission

Hospitals, ambulatory care, behavioral health, home care, and hospice, long term care, laboratories and office based surgery centers can all be accredited by JC.

The term used to describe a combination of paper-based and electronic health records is:

Hybrid

What is record reconciliation?

Hybrid System, upon patient discharge, receipt of the health record is checked with a discharge list for completeness.

Goals of CDI Tool Kit

Identify and clarify missing, conflicting, or nonspecific physician documentation related to diagnoses and procedures; Support accurate diagnostic and procedural coding, DRG assignment, severity of illness, and expected risk of mortality, leading to appropriate reimbursement; promote health record completion during the patient's course of care; Improve communication between physicians and other members of the health care team; provide education; improve documentation to reflect quality and outcome scores; improve coders clinical knowledge

Administrative Data

Includes demographic and financial information, as well as authorizations and consents related to the provision of care.

Information-oriented Management Practice

Includes tasks associated with a broad range of information services - emphasizing data manipulation and information management tasks and focusing on the provision of an extensive range of information services

In a paper-based system, the completion of the chart is monitored in a special area of the HIM department called the:

Incomplete record file

CAHIM (Commission on Accreditation for Health informatics and information Management education)

Independent accrediting organization whose mission is to serve the public interest by establishing and enforcing quality accreditation standards for health informatics (HI) and health information management (HIM) education programs.

Patient self-management

Individuals have taken a more active role in managing their own healthcare and therefore becoming a primary user of the health record. Ex - document services received, proof of identity, self-manage care, verify billing

Patient Care Delivery (providers)

Individuals that provide direct patient care such as physicians, nurses, chaplains, pharmacists etc.

Future directions in Health Information Management Technology:

Influencing factors: - Political initiatives - Expansion of Network capabilities - Emergence ofnew technologies such as EHRs, natural language processing, and computer-assisted coding -Move toward ICD-10-CM and ICD-10-PCS - Societal and regulatory requirements for information privacy and security - Greater demand and accountability for improved healthcare quality and patient safety that can be facilitated through the use of information technology - Increased consumer knowledge of personal healthcare decisions and increased focus on personal health records

Financial and other administrative processes

Information in the health record determines the payment the provider will receive in every type of reimbursement system. Ex. document services for payment, bill for services, submit insurance claims, manage costs

According to AHIMA, what can provide for quality discrete, structured data that are more easily manipulated and analyzed?

Input masks, lookup values, and validation rules

Physicians Orders

Instructions the physician gives to the other healthcare professionals who actually perform diagnostic tests and treatments, administer medications.

Workers Comp

Insurance system operated by individual states, to provide healthcare services to those injured at work.

Strategies for MPI Integrity

Integrity must be maintained in order to avoid patient safety, customer service, risk management, legal and other issues. MPI cleanup process - uses matching algorithms to identify and fix these problems. 3 types: are often part of the MPI application: a DETERMINISTIC algorithm requires an exact match of combined data elements such as name, birth date, sex, and social security number. PROBABILISTIC algorithm is base on complex mathematical formulas that analyze facility specific MPI data to determine precisely matched weight probabilities for attribute values of various data elements. RULES-BASED algorithm assigns weights, for significant values, to particular data elements and later uses these weights in the comparison of one record to another.

Diagnostic/Therapeutic Services

Involve the work of Allied Health professionals

Respiratory Therapy

Involves the diagnosis and treatment of patients who have acute/and or chronic lung disorders. Respiratory Therapists provide services such as emergency care for stroke, heart failure, and shock patients, and other chronic lung diseases. Work under direction from the physician.

Nuclear Medicine

Involves the use of ionizing radiation and small amounts of short lived radioactive tracers to treat disease - specifically cancers; performed by radiologists.

Radiology

Involves the use of radioactive isotopes, fluoroscopic and radiographic equipment, and CT and MRI equipment to diagnose disease. Radiologists: Physicians whom are experts in the medical use of radiant technology etc and interpreting results. Radiology Techs: allied health professionals trained to operate radiological equipment and perform tests under supervision of a radiologist.

Which of the following is not true about document imaging? a. It allows random access for retrieval of documents. b. It can be viewed by more than one person at a time. c. It can be viewed from locations remote from the HIM department. d. It is a paperless system.

It can be viewed from locations remote from the HIM department.

Problem Orientated Health Record

Itemized list of the patient's past and present social, psychological, and medical problems - each problem is identified by a unique number.

Which of the following is not true of good forms design for electronic forms? a. Keystrokes should be minimized by using pop-up menus. b. Electronic forms should use completeness checks. c. Electronic forms should use radio buttons for multiple selections of items. d. Electronic forms should use text boxes to enter text.

Keystrokes should be minimized by using pop-up menus.

Diagnostic results

Lab tests; pathology reports; imaging procedures

Clinical Laboratory Science

Laboratory Tech's perform test's on body fluids, tissue and cells, Pathologists analyze the tests results.

Health Information and Management Systems Society (HIMSS)

Lead healthcare transformation through effective use of health information technology - Exam covers topics such as healthcare, technology, system analysis, system design, privacy and security, and administration.

CEO

Leader of administrative Staff; implements policies and strategic direction set by the hospital's board of directors.

health record that is maintained as the business record and is the health record that may be disclosed to authorized users and for evidentiary purposes

Legal Health Record - facility must have a policy identifying the legal health record

In healthcare organizations, what is the database that is used to locate the medical record number usually called?

MPI

What is the key to the identification and location of a patient's health record?

MPI

Destruction services for destruction of records

MUST meet HIPPA Privacy Rule and in addition: Indemnify the healthcare facility from loss due to unauthorized disclosure Require that the business associate maintain liability insurance in specified amounts, at all times the contract is in effect. Provide proof of destruction Specify the method of destruction Specify the time that will elapse between acquisition and destruction of data The method of destruction should be reassessed annually, based on current technology, accepted practices, and availability of timely and cost-effective destruction services.

Public Law 92-603 of 1972

Mandated Utilization review of medicare patients at Hospitals and Extended Care Facilities - Goal to make sure medicare patients were receiving care that was medically necessary

What is the most important index used by the HIM department? What is it? What is its function?

Master Patient Index (MPI) and is the permanent record of every patient ever seen in the healthcare entity. The MPI functions as the primary guide to locating pertinent demographic data about the patient and his or her health record number. It is the initial point of documentation of the health record

The primary guide to locating a record in a numerical filing system is the

Master Patient Index MPI

Medicaid

Medical Assistance program for low-income Americans; Covers Inpatient/Outpatient care, Lab and xray services; SNF and home health; physician services; Family Planning; Rural Health, Early and periodic screenings, diagnosis and treatment services

Obstetric/Gyno documentation

Medical History to include abuse, neglect, and sexual practices, periodic lab testing, additional lab testing for high risk groups

Flexner's Findings

Medical school applicants lacked knowledge of the basic sciences, hospital-based training, and unacceptable levels of medical skill.

Reforms after Flexner's Findings

Medical students applicants must hold a college degree, medical training must be founded in basic sciences, students must also receive hospital based training.

The function within the HIM department responsible for listening to dictated reports and typing them into a medical report format is called:

Medical transcription

MS-DRG/ APC groupers

Medicare severity diagnosis related group APC groupers are software programs that help coders determine the appropriate ambulatory payment classification for outpatient encounters.

Board Members

Members are elected or appointed for specific terms of service

American Hospital Association (AHA)

Mission: To facilitate the interchange of ideas, comparing and contrasting methods of management, the discussion of hospital economics, the inspection of hosptials, suggestions of better plans for operating them, and such other matters as may affect the general interest of the membership; Created for: Hospitals; Publishes Coding Clinic - provides ICD-9-CM coding advice.

National Institute of Health

Mission: To uncover new medical knowledge that can lead to health improvements for all.

What type of paper-based storage conserves floor space by eliminating all but one or two aisles?

Mobile filing units

Standardization of Hospital Care

More focus on patient outcome. Reforms led to formation of American College of Surgeons in 1913. Formed the Minimum Standards.

Patient Care Services

Most direct care delivered in hospitals is provided by nurses; playing a wider role in treatment planning and case management

Licensure Requirements

Most health care organizations must be licensed before providing care to a patient.

Joint Commission

Nation's oldest and largest healthcare standards-setting body; Accredits Hospital, Home Care, Nursing Homes and Long-term care facilities, behavioral health, Ambulatory care providers; independent/free standing clinical Labs; 50% of standards relate to patient safety; ORYX initiative was to incorporate the ongoing collection of quality and performance data into the accreditation process.

Joint Commission Safety Programs

National Patient Safety Goal; Sentinel Event Policy; Sentinel Event Alert; Universal Protocol.

Medical Record Clerk

New staff had to be hired to meet new medical standards. Their job was to maintain, organize and file the medical records.

Under the False Claims Act, claims may be brought up to how many years?

No more than 7 years

For-Profit/Non-Profit Status

Non-Profit hospitals use excess funds to improve their services and to finance educational programs and community services. For-Profit organizations are privately owned. Excess funds are paid back to the managers, owners and investors in the form of bonuses and dividends.

CCHIT (Certification Commission for Health Information Technology)

Non-profit org, mission to accelerate the adoption of heath information technology. Recognized by the federal government as one of 6 organizations that can certify EHR's.

Measures that limit an EHR user's ability to deny (repudiate) the origination receipt or authorization of a data exchange by that user

Nonrepudiation - means to accept ie. electronic signatures

Pre-OP Notes

Notes are made by the anesthesiologist and surgeon prior to the procedure and nurses report preoperative patient preparations.

Classification of Hospitals

Number of Beds; Types of services provided; Types of patients served; For-Profit/Non-profit status; Type of ownership

In a paper-based system, the HIM department routinely delivers health records to:

Nursing units

Occupational Therapy

Occupational therapists OT's evaluate and treat patients whose illnesses or injuries have resulted in significant psychologist, physical or work-related impairment.

Health Savings Account

Offer members the opportunity to control how their healthcare dollars are spent with a tax-advantage savings account and comprehensive medical insurance coverage. Use it or lose it. Benefits: Member pays for this deductible with pretax dollars, this means the member saves the money that ordinarily would have gone to pay taxes, which in effect, decreases the cost of the deductible.

What can function as a MPI?

Often the patient registration system aka registration, admission, discharge, and transfer system (R-ADT) functions as the MPI

Which of the following is an advantage of a centralized unit filing system?

One location in which to look for records

What are the benefits of document imaging?

One of the greatest benefits of document imaging is increased efficiency by eliminating the requirement to move and track paper documents through workflow. Also helps solve the problem of lost or misplaced paper or microfiche documents. It saves money by reducing the need for storage space and by decreasing the work of file clerks.

Active Membership

Open to all individuals interested in AHIMA purpose and willing to abide by the Code of Ethics.

If one needed to know the number of C-sections performed by a specific obstetrician, which of the following indices would be used to identify the cases?

Operation index

Medicare Part C

Option for beneficiaries to receive Medicare benefits through private insurers.

Medicare Part B

Optional; must pay a premium; helps supplement federal funding; helps pay for physician's services, outpatient hospital care; medical services and supplies and other costs not covered by Part A

Deemed Status

Organizations whom have standards that sufficiently cover COP are given deemed status - and do not have to go through separate medicare surveys. Joint Commission, Det Norske Veritas Healthcare, AOA - all have deemed status.

The tool used to track paper-based health records is

Outguide

What is the most common type of tracking system used to track paper-based health records?

Outguide - usually made of strong colored vinyl with two plastic pockets. It is the size of a regular record folder and is placed in the record location when the record is removed from the file.

Patient Care Management and Support

Oversee the services provided to patients within their organizations. The health record provides the data they need to evaluate the performance of individual patient care providers and to determine the effectiveness of the services provided Ex. Administrators, Financial managers and accountants, quality managers, records professionals, risk managers, unit clerks and utilization review managers

What is used to determine compliance with the Joint Commission standards?

PPR - periodic performance review PFP - Priority focus process that facilitates the newer continual standards, compliance process

Medicare Part A

Paid for by Payroll Taxes; covers hospitalization, long-term care and home health

Accreditation Organizations

Participating health care organizations is subject to periodic review. A key component of this is reviewing the health record.

A functionality of the electronic health record that allows patients access to their protected health information (for example, lab results) is:

Patient Portal

Rehab documentation

Patient assessment Instrument (PAI) - completed upon admission and upon discharge.

Patient Care Management

Patient care management refers to all the activities related to managing the healthcare services provided to patients. Ex. document case mix in institutions and practices, analyze severity if illness, formulate practice guidelines, manage risk

Patient Care support services

Patient care support services encompasses the activities related to the handling of the healthcare organizations resources, the analysis of trends, and the communication of information among different clinical departments. Ex. allocate resources, analyze trends and develop forecasts, asses workload

Patient Consent Documents

Patient must consent to a procedure after an explanation and an opportunity to ask questions.

Paper based identification systems patient ID: Serial numbering System

Patient receives a unique numerical identifier for each encounter or admission to a healthcare facility. Disadvantage: information about the patient's care and treatment is filed in separate health records and at separate locations. retrieval more difficult. inefficient.

In which department/unit does the health record typically begin?

Patient registration

The health record number is typically assigned by:

Patient registration

Where does the health record begin?

Patient registration

The computer system that may serve as the MPI function is the:

Patient registration system

Patient Care Delivery (consumers)

Patients and Families

Behavioral Health Services

Patients used to be locked away in mental institutions; more focus on medications and outpatient therapy; Insurance coverage for services has always lagged behind other medical coverage; insurers restrict behavioral health coverage - high copays, limited visits.

North America's First Hospital

Pennsylvania Hospital was established in 1752 with the help of Benjamin Franklin.

AHIMA's recommended retention standards

Permanently: Master Patient Index (MPI), Register of Births, Register of Deaths, and Register of surgical procedures 10 Years: Disease Index, Operative Index, and Physician index 10 Years after the age of majority: Fetal heart monitor records 10 Years after the most recent encounter: Patient health/medical records (adults) 5 Years: Diagnostic images (such as x-ray film) (adults) 5 Years after the age of majority: Diagnostic images (such as x-ray film) (Minors) Age of majority plus statue of limitations: Patient health/medical records (Minors)

Authorization

Permission granted by the patient or the patient's representative to release information for reasons other then treatment, payment or healthcare operations.

Interoperability

Permit the the electronic exchange of patient information within a region and within the nation

PHR Systems

Personal Health record systems - health care record initiated and maintained by an individual. Comprised of information from the individual and healthcare providers. No mandates for an individual to maintain a PHR.

Clinical Support Services

Pharmaceutical Services; Food and Nutrition Services; HIM services; Social work and Social Services; Patient advocacy services; Environmental (housekeeping) services; Purchasing, Central Supply, and materials management services; engineering and plant operations

Private Medical Practice

Physician owned entities that provide primary care or medical/surgical speciality care services in a freestanding office setting; these physicians have medical privileges at local hospitals and surgical centers but are not employees of the other healthcare entities

Statements that describe general guidelines that direct behavior or direct or constrain decision making are called:

Policies

Version control of documents in the EHR requires:

Policies and procedures to control which version(s) is displayed.

Manage Care

Prepaid Healthcare plans for example - PPO's (preferred Provider organizations) HMO's (health maintenance organizations) - work to control the cost of and access to healthcare services while striving to meet high-quality standards

Effects of the Great Depression

Prepaid health plans: Blue Cross - covered hospital services and Blue shield - physician services.

Medicare Part D

Prescription Drug Plan; Plans choose which drugs or classes or drugs they wish to cover; at what level they wish to cover them, and are free to not cover them at all.

Ambulatory Care

Preventative and/or corrective healthcare provided in a practitioner's office, a clinic, or a hospital as an outpatient.

Board of Directors

Primary Role: Setting overall direction of the hospital; other responsibilities - Establishing bylaws in accordance with the organizations legal and licensing requirements; selecting qualified administrators; Approving the organization and makeup of the clinical staff; monitoring the quality of care.

Primary Users

Primary users of health care records are patient care providers.

Health Record

Principal repository for data and information about health care services provided to an individual patient. Documents the who, what, where, why and how of patient care. Also records the health status of a patient.

Certification

Procedure conducted by an authorized body in evaluating and recognizing whether an individual or institution meets predetermined requirements

Step by step instructions on how to complete a specific task are called:

Procedures

American Health Information Management Asso. (AHIMA)

Professional membership organization for mangers of health record services and health care information. "to lead the health informatics and information management community to advance professional practice and standards" Vision: "leading the advancement and ethical use of quality health information to promote health and wellness worldwide. Has two areas: CAHIM (commission on Accreditation for Health Informatics and Information Management Education) CCHIIM (commission on certification for health informatics and information management).

Individual users

Professionals who provide direct patient care services includes physicians, nurses, nurse practitioners, allied health professionals

Social Security Act of 1935

Programs for "Old Age and Unemployment". Provided states funding for maternal and infants, rehab of crippled children, public health and for children under 16.

Administrative Support Services

Provide business management and clerical services in several key areas: Admissions and Central Registration; Claims and Billing; Accounting; Information Services; HR; PR; Fund development; Marketing

Ancillary Support Services

Provide clinical and administrative support services to patients, medical staff, visitors and employees

Free-Standing Ambulatory Care Centers

Provide emergency care and urgent care for walk-in patients.

Surgical Technologist

Provide surgical care to patients in a variety of settings; majority of them in hospital operating rooms.

Freestanding Ambulatory Surgery Centers

Provide surgical procedures that take anywhere from 5-90 mins to perform and require less than 4hours recovery.

Adult Day Care Programs

Provides a wide range of health and social services to elderly persons during the day; targeted to elderly patients who regular care giver works during the day.

HITECH component to ARRA

Provides funding to community colleges to train individuals in the following roles: -Practice workflow and information management redesign specialists -Clinician/practitioner consultants -Implementation support specialists - Implementation managers -Technical/software support staff -Trainers

The forms design committee:

Provides oversight for the development, review, and control of forms and computer screens

Universal Protocol

Provides protocol to prevent surgical mishaps such as procedures performed on the wrong person or wrong site.

Patient bill or rights

Provides the patients rights while under care at a facility. Must include - Know who is providing treatment, confidentiality, receive information about treatment, refuse treatment, participate in care planning, be safe from abusive treatment

Which of the following is the appropriate method for destroying microfilm?

Pulverizing

Removing health records from the storage area to allow space for more current records is called:

Purging records

Maintenance - To ensure the integrity of the MPI, several quality control mechanisms are essential and include:

Quality - MPI prone to errors: misspellings, incorrect demographic data, transposition of numbers, and typographical errors are a few. Can cause treatment errors, billing problems and distorting data analysis of the organization's patient population. Duplicate, Overlay, and Overlap Medical Record Number Issues - Patient info not found upon admission and new record created; Or patient matched with wrong health record

AHIMA Vision

Quality healthcare through quality information

Medical Review Organizations

Quality improvement organizations evaluate the adequacy and appropriateness of the care provided by healthcare organizations

Respiratory Therapy

RT's evaluate, treat and care for patients with breathing disorders.

Health Information Management

Recognized as an allied health profession since 1928.

What facilitates efficiency, accuracy, and completeness of the health record?

Record Processing

Which of the typical HIM functions assist in monitoring and compliance of the health care facility with Joint Commission standards?

Record Processing

Critical support services managed by HIM

Record processing, Monitoring of record completion, transcription, release of patient information, clinical coding, abstracting, and clinical data analysis

Medical Staff Classification

Refers to the organization of physicians according to clinical assignment

Basic Components of the acute health care record

Registration record; Medical history; Physical exam; Clinical Observations; Physician's order; Reports of diagnostic and therapeutic procedures; Consultation reports; Discharge summary; Patient instructions; Consents, authorizations, and acknowledgements

A chronological listing of data is called a/an?

Registry

Biologics Control Act of 1902

Regulated the creation of vaccines and sera sold via interstate commerce. Authority to test and improve biological products. Research on controlling epidemics. Now the National Institute of Health - since 1930

Patient Care Reimbursement

Reimbursement is based on the documentation in the health record. Coders identify the patients diagnoses as well as other services and assign a code, which is then used to generate a patient bill Ex. Benefit managers, Insurers (federal, state and private)

Secondary Purposes

Related to the environment in which patient care is provided.

Reviewing requests for health record copies and determining if they are valid is part of what function within the HIM dept?

Release of Information (ROI) function

Subacute Care

Represents a new movement in healthcare; refers to the level of skilled care needed by patients with complex medical conditions, typically medicare patients with multiple medical problems

Physical Examination Report

Represents the attending physician's assessment of the patient's current health status after evaluating the patient's physical condition.

Patient Self-determination Act

Requires health-care providers to provide a written information on the patient's rights to execute advance directives.

Which of the following is a request from a clinical area to charge out a health record?

Requisition

Third Party Payers

Responsible for the reimbursement of healthcare services covered by some kind of insurance program. Review individual health records to determine whether documentation supports the providers claim for reimbursement.

Reviewing the record for deficiencies after the patient is discharged from the hospital is an example of what type of review?

Retrospective

What microfilm format is inefficient when patients have multiple admissions on microfilm?

Roll

Which type of microfilm does not allow for a unit record to be maintained?

Roll microfilm

In which numbering system does a patient admitted to a healthcare facility on three different occasions receive three different health record numbers?

Serial

Which numbering systems is best for maintaining the encounters of a patient together?

Serial-Unit

Regulation

Serve as evidence in litigation; foster postmarking surveillance; assess compliance with standards of care; accredit professionals and hospitals; compare healthcare organizations

Which of the following is an example of how the HIM professional interacts with the medical staff

Serves on medical staff committee

American College of Healthcare Executives (ACHE)

Serves: Hospital Administrators; "the professional membership society for healthcare executives; to meet members' professional, educational and leadership needs; to promote high ethical standards and conduct; and to enhance healthcare leadership and management excellence.

Department of VA

Services healthcare to eligible veterans of military services

Community-based Ambulatory Care

Services that are provided in a freestanding clinic facilities that are not owned by or affiliated with a hospital

Acute Care

Short-Term care provided to diagnose/and or treat an illness or injury

Features of Screen design:

Should be evaluated for features that will contribute to the capturing of quality health data and will provide ease of use, which in turn help to provide quality data. -Clear navigational buttons - direct the user to the next step in the documentation process and buttons to view the previous screen are imperative to assuring the user can use the system with ease. - Clear labeling of buttons and data fields - Limiting the use of abbreviations on buttons and data fields - Consistent location on the screen of navigation buttons - Built-in alerts to notify the user of possible errors - Availability of references at the appropriate data field - Prompt for more information where appropriate -checks for warning signs or errors

Delivery of Long-Term Care

Skilled Nursing Facilities/Nursing Homes - round the clock nursing care and other rehab services; Residential Care Facilities: Provides a lower level of care, assistance is available when needed; Hospice Care - patients whom are diagnosed with a terminal illness, with limited life expectancy - allows patient to live out their life as comfortable as possible.

Clinical Laboratory Services

Split in to two sections: anatomic pathology and clinical pathology. Pathologists: Physicians who specialize in performing and interpreting the results of pathology tests. Lab Techs are allied health professionals trained to operate laboratory equipment and perform laboratory tests under supervision of a pathologist.

Expressed consent

Spoken or written.

How do they ensure the integrity of patient identity in health information exchange

Standardization of health information exchange practices is paramount.

Statements that define the performance expectations and/or structures or processes that must be in place are:

Standards

Council on Quality and Leadership in Support for People with Disabilities (CARF)

Standards for facilities that specialize in mental health and disabilities.

Facility-Specific Standards

Standards might be found in facility policies and procedures, medical bylaws, rules and regulations

Accreditation Standards

Standards that must be met in order to be accredited by an outside accrediting organization.

Record retention should be based on:

State regulations and AHIMA recommendations

Audiology

Studies hearing and balance related disorders. Audiologist's treat those with hearing loss and prevent related damage.

Subjective, Objective, Assessment Plan (SOAP)

Subjective: Entry relates significant information in the patients word or from the patients point of view; Objective: Includes factual information such as labs or provider observations; Assessment: Professional conclusions reached from evaluation; Plan: the plan of care until next encounter.

deemed status

TJC accredited hospitals are also deemed to be in compliance with the Medicare Conditions of Participation. - Medicare makes random surveys as well

Consider the following sequence of numbers: 12-34-55, 13-34-55, and 14-34-55. What filing system is being used if these numbers represent the health record numbers of three records filed together within the filing system.

Terminal digit filing

Which filing system is considered to be the most efficient?

Terminal-digit

One of the most sought after accreditation distinction by healthcare facilities is offered by the:

The Joint Commission

What groups have established the standards for health record documentation?

The Joint Commission (TJC) and state licensing bodies as well as Medicare Conditions of Participation (MCoP), National Committee for Quality Assurance (NCQA), American Accreditation Health Care Commission/Utilization Review Accreditation Commission, American Osteopathic Association, Commission on Accrediitation of Rehabilitation Facilities, Health Accreditation Program of the National League of Nursing, College of American Pathologists, American Association of Blood Banks, American College of Surgeons, Accreditation Association for Ambulatory Health Care, and American Medical Accreditation Program. The Joint Commission offers an accreditation program for hospitals and other healthcare orgs based on pre-established accreditation standards.

How are amendments handled in the EHR?

The amendment must have a separate signature, date and time.

Who were first to develop the study of medicine?

The ancient Greeks - surgical procedures, documented clinical cases, and created medical books.

Access Control for EHRs

The center of Medicare and Medicaid Services EHR certification criteria requires access control of the EHR. It states: "Assign a unique name and/or number for identifying and tracking user identity and establish controls that permit only authorized users to access electronic health information"

Data Accuracy

The data is correct. Depends on: Patients physical health and emotional state at the time the data was collected; providers interviewing skills; providers recording skills; availability of the patient's clinical history; dependability of the automated equipment; reliability of the electronic communications media.

Retention of EHR

The facility must consider state and federal regulations, statutes of limitation, research and educational needs, and patient care needs. There must also be a policy for the destruction of computer equipment and computer storage media when it is no longer functioning or has become obsolete.

Primary Function

The health record's primary function is to store patient care documentation.

What dictates how the specific functions are carried out?

The medium in which the information is stored.

Traditional Practice

The program emphasized the need to ensure that complete and accurate medical records were complied and maintained for every patient. Accurate records were needed to support the care and treatment provided to the patient. Activities centered primarily on the medical record or reports, within the record as a physical unit rather than on the data elements that make up information within the medical record.

AHIMA Values

The public right to accurate and confidential personal health information; Innovation and leadership in advancing health information mangt. practices and standards worldwide; Adherence to the AHIMA Code of Ethics; Advocacy and interdisciplinary collaboration with other professional organizations.

Institutional Users

These are users that use collected dated to manage resources, planning and marketing services.

How are materials from other facilities documented in the EHR?

They are scanned and filed in the EHR.

What is the determining factor in whether a document is considered part of the legal health record.

This is not determined by where the information resides or its format, but rather how the information is used and whether it is reasonable to expect the information to be routinely released when a request for a complete health record is received.

AHIMA Mission:

To be the professional community that improves healthcare by advancing best practices and standards for health information management and the trusted source for education, research, and professional credentialing.

What is the goal of the health record system?

To ensure that accurate information is available to authorized users to support quality patient care.

American Nurse's Association

To work for the improvement of health standards and the availability of healthcare services. Association serves Nurses.

True or False: Data quality begins at the point of creation

True

True or False: EHR data are captured by scanning and direct entry.

True

True or False: Policies should address how the patient information will be removed from computers at the end of their useful life.

True

True or false Addendums should document the date the event actually happened - not the date it was documented

True

True or false The best practices for forms design is to use white paper with black ink

True

In which system are all encounters or patient visits kept in one folder?

Unit numbering system

The system in which a health record number is assigned at the first encounter and then used for all subsequent healthcare encounters is the:

Unit numbering system

Healthcare delivery organizations

Use data from the health record to evaluating and monitoring of resources, seeking reimbursement, planing and marketing services

Communities of Practice (CoP)

Virtual network of AHIMA members who communicate via a web-based program management by AHIMA - provides communities for members to contact others for quick problem solving, support, advice, best practices etc.

New Roles and Opportunities

Vision 2006 Initiative identified new areas and opportunities for HIM Professionals

What is another method used to capture dictated reports in the EHR

Voice recognition technology - computer software captures the dictation and converts the dictation to text. Back end voice recognition software or voice recognition at the point of transcription is most commonly used for routine transcription of reports. As the practice of medical transcription evolves and voice recognition software is utilized, emphasis is placed on medical language editing, data quality control, and text/document management.

What is overlap?

When more than one medical record number exists for the same patient within an enterprise at different facilities or in different databases. Often occur in organization with multiple facilities or can occur in the health information exchanges. Frequently problem arises when there are facility or organization mergers and an enterprise master person/patient index (EMPI) is created

Speech Language Pathology and Audiology

Work with patients whom have speech/and or audiology problems.

What are the benefits of an electronic system?

ability to access data by more than one individual at a time, edit checks can be applied against specific fields in the database to better ensure data accuracy, can be easily cross-referenced (when a patient has used more than one name during hospital or clinic visits), permits the use of several search techniques for locating an existing patient's information.

coding professional responsibilities include

abstracting data and assigning codes using ICD-9-CM and CPT for a hospital stay and for translating healthcare providers' diagnostic and procedural documentation into coded form using code sets such as ICD-9-CM, CPT, HCPCS Level II. May be done manually or by using an Encoder. MS-DRG and APC groupers for acute care hospitals.

addendum

additional health information within the health record: Document the current date and time Write addendum and state the reason for the addendum, referring back to the original entry. Identify any sources of information used to support the addendum When writing an addendum, complete it as soon after the original note as possible.

Major functions of revenue cycle management

admitting/access management, case management, charge capture, HIM, patient financial services/ business office, finance, compliance, and information technology.

Errors

another step to managing the quality data in EHR. Most generate error reports or utilize error queues when there are mismatches between the EHR and the other computer systems that feed information into the EHR. Must be a process in place to correct the errors.

Validation rules

are applied to data fields to determine the validity of data entered into the EHR. Features include:drop-down menus, built-in data values, and check boxes. They do limit the practitioner to document complex cases

Privacy

as the right of individuals to control access to their personal information.

Primary Purpose of the Health record

associated directly with the provision of patient care services as well as documentation of the patient's health status.

Second element of access control

authentication - the act of verifying a claim of identity, CMS states "verify that a person or entity seeking access to electronic health information is the one claimed and is authorized to access such information"

Medical transcription

automated computer medical dictation (or voice capture) systems for dictating reports (clinical history, physical examination, consultation report, operative report, discharge summary, pathology reports, and radiology reports) It is stored in either tape or disk format and retrieved by the transcriptionists, typed or stored electronically in the EHR. The role of medical transcriptionist is that of a language editor.

Which of the following is a disadvantage of alphabetic filing? a. Easy to train new personnel to file b. Uneven expansion of file shelves or cabinets c. Ease of creation d. No reliance on an index or authority file

b. Uneven expansion of file shelves or cabinets

Data quality of EHR

begins at the point of creation. Managing data input through good design of end-user interfaces increases the probability of quality data.

registry

chronological listing of data

amendments

clarification made to the health information after the original documentation has been final signed by the provider. Date, time, signed and attach to the original document that it is amending.

Computer Assisted coding (CAC)

computer software used to generate ICD-9-CM or ICD-10-CM/PCS and CPT codes for each episode of care.

Discharge Summary

concise account if the patients illness, course of treatment, response to treatment, and condition at the time of patient discharge - ensures the continuity of care, provides information to support the activities of the medical staff review committee, provides information that can be used to answer information requests from authorized individuals or entities. Must be signed by the physician.

Industry

conduct research and development; plan marketing strategy

Transfer record

consists of a brief review of the patient stay along with current status.

Data quality management

data applications: the purposes of which data are collected; data collection: The processes by which data are collected; Data Warehousing: the processes and systems by which data are archived; Data analysis: the processes by which data are translated into information that can be used for designated applications

Data consistency

data is reliable.

Data currency

data is up-to-date

data timeliness

data must be recored at or near the time of the event or observation

CCHIM

dedicated to assuring the competency of professionals practicing HIM. CCHIM serves the public by establishing, implementing and enforcing standards and procedures for certification and recertification of HIM professionals. Also provides strategic oversight for all AHIMA certification programs.

When a hospital accredited by Joint Commission is considered to be in compliance with Medicare's Conditions of Participation, this is called:

deemed status

Incomplete records that are not completed by the physician within the time frame specified in the healthcare facility's policies are called:

delinquent records

Operative report

describes the surgical procedures performed on the patient

Autopsy report

description of the examination of a patient's body after they have died. Purpose is to determine cause of death or to gain more information about the disease.

operation index

diagnoses and operative codes, like those used in a classification system such as ICD-9-CM are used as guides or pointers to the health records of patients who have had a specific disease or operation. They are essential for locating health records to conduct quality improvement and research studies, as well as monitoring quality of care

Education

document the experience of healthcare professionals; prepare conferences and presentations; to teach healthcare students.

Progress Notes

documentation of clinical notes can only be made by authorized health care providers as stated in medical staff by laws

Consultation report

documents the clinical opinion of a physician and other han the primary or attending physician.

Paper based corrections

draw a single line through the original entry, writing error above the entry and then the practitioner signs, dates, and times the correction.

ad hoc reporting capabilities

enable the user to select the field items he or she wants in the reports

Who governs the release of health record information?

federal regulations such as the Health Insurance Portability and Accountability Act (HIPPA) and state laws. To comply with HIPPA standards, a healthcare facility MUST maintain a record that accounts for all disclosures from the health record.

Community college consortia to educate health information technology professionals

funding came from ARRA - created a program for Health IT professionals to complete in 6 months or less to train them for the implementation of electronic health care records

Patient Instructions

given to the patient upon discharge so that the recovery process that begun in the hospital continues.

index

guide that serves as a pointer or indicator to locate something

general direction about the design of the form

guideline

CAHIM

has sole and independent authority in all matters pertaining to accreditation of educational programs in HIM. It is the accrediting agency for degree-granting programs in HIM.

Integrated Delivery System (IDS)

healthcare provider made up of a number of associated medical facilities that furnish coordinated healthcare services; purpose is organize the continuum of care and reduce costs.

combination of paper-based and electronically stored healthcare records

hybrid record - it is a transitional health record that at some point becomes an electronic health record.

Where should the process for checking patient records be located?

in the facility's charting policies and procedures

What is the foundation on which access control is based?

includes: identification, authentication, and authorization. Basic building block is identification usually performed through the user name and authorization

deficiency slip

indicates what reports are missing or require authentication and enters this information into a computer system that logs and tracks health record deficiencies or maintains a copy of the deficiency slip in a tickler file. A record with deficiencies is called AN INCOMPLETE RECORD.

HIM functions are:

information centered and involves ensuring information quality, security, and availability.

Resequencing

involves moving a document from one place to another within the same episode of care. No annotation is needed.

reassignment (synonymous with misfiles)

involves moving the document from one episode of care to a different episode of care within the same patient record. An annotation should be viewable to the clinical staff so that the reassigned document can be considered if needed

retraction

involves removing a document from standard view, removing it from one record, and posting it to another within the electronic document management system. An annotation should be viewable to the clinical staff so that the retracted document can be consulted if needed.

Revenue Cycle Management

is a system that involves several processes working together to ensure that the healthcare facility is properly reimbursed for the services provided.

Feature of clinical decision support systems

is the availability of references - allows the physician to easily look up information without having to rely on memory in prescribing medications or considering a course of treatment.

data precision

is the terms used to describe expected data values

NONREPUDIATION measures

limit an EHR user's ability to deny (repudiate) the origination, receipt, or authorization of a data exchange by that user" (ie signatures as example)

Board Members include:

local business leaders, representatives of community organizations, and others interested in the welfare of the community.

Complex case entries

may require the physician to use free text to adequately document a patient's condition. Free text is unstructured data and limits the facility's ability to report data.

Data Comprehensiveness

means that all the required data elements are included in the health record - must contain Patient identification; consents of treatment; advance directives; problem list; diagnoses; clinical history; diagnostic test results; treatments and outcomes, Conclusions and follow up requirements.

Data definition

means the data and information documented in the health record are defined. Users must understand what the data means and represents

Quality Management 3 fundamental tasks

measurement, assessment and improvement

When searching for a patient's record, what data elements can be used?

medical record or billing number, date of birth, or social security number.

Occupational Therapy

medically directed use of work and play activities to improve patient's independent functioning, enhance their development, and prevent or decrease their level of disability. Occupational therapists work under the direction of the physician.

Public Health and Homeland Security

monitor public health; monitor bioterrorism activity

Unit numbering system

most commonly used in large facilities. Patient receives a unique number on his first admission and the same number is used for subsequent encounters. Method most commonly used as the unique identifier in the EHR environment.

What language is behind the CAC engine

natural language processing (NLP) it analyzes text and extracts implied facts as coded data. The assigned codes are reviewed by the medical coding professional to assure the accuracy of the CAC

Anesthesia report

notes any preoperative medication and response to it, the anesthesia administered with dose and method, duration of administration and the patient's vital signs while under anesthesia.

Serial Unit Numbering System

numbers are assigned in a serial manner, just as they are in the serial numbering system. However, during each new patient encounter, the previous health records are brought forward and filed under the last assigned health record number.

Purged records

old records are removed from the file area. These records are often microfilmed, sent to off-site storage facilities or scanned.

Standing orders

order medical staff or an individual physician have established as routine care for a specific diagnosis or procedure

Research Organizations

organizations performing healthcare-related research study the current healthcare environment to prove or disprove hyptheses related to disease processes and treatments.

Paper record assembly

organized or assembled after the patient is discharged from the hospital or other setting - each page in the patient record is organized in a pre-established order

The management of high-quality, error free MPI requires constant maintenance that includes: What is first line of defense?

oversight, evaluation, and correction of errors. Prevention of problems should be the front line of defense. Communication back to the department responsible for the errors is key to providing awareness of the importance of the MPI and identifying opportunities for training and workflow issues.

Maintenance of destruction documentation

permanently - These are called certificates of destruction.

concurrent review

personnel from the HIM department go to the nursing unit daily (or periodically) to review each patient's record - review occurs concurrently with the patient's stay in the hospital.

Which of the following could be used to determine if someone has the right to view a health record?

photo identification

Amendments and Corrections in EHRs

policies must be in place to assure the integrity of the information contained in the health record as a business record, as a legal health record, and as a patient care communication tool. The facility must have written policies that specify who, when, and how amendments, corrections, and deletions may be made to a health record.

Data mining

process of analyzing data from different perspectives and summarizing it into useful information. Analytical tool for large amounts of data. It is the"process of extracting information from a database and then quantifying and filtering discrete, structured data" (AHIMA)

Release of Information (ROI)

protecting the security and privacy of patient information is one of the healthcare institution's top priorities. HIM has responsibility for determining appropriate access to and release of information from patient health records.

Security

protection of the privacy of individuals and the confidentiality of health records - can also refer to physical protection of the record.

Voluntary Agencies

provide healthcare and healthcare planning services, usually at the local level to low-income patients. Services range from giving free immunizations to family planning counseling. Ex. Red Cross

HIM is rapidly changing due to?

provisions mandated by the American Recovery and Reinvestment Act (ARRA) for the implementation of the electronic health record by 2014

retrospective review

quantitative analysis is completed the day following the patient's discharge from the hospital.

review and analyze to acertain that there are no missing reports, forms, or required signatures and that all documents contain the patient's name and health record number - review for deficiencies called:

quantitative analysis or record content review

Which term is the process of checking individual data elements, reports, or files against each other to resolve discrepancies

reconciliation

The process of assuring that all records of discharged patients have been received by the HIM department for processing is called:

record reconciliation

Dual work processes

refer to coexisting paper and electronic processes used in the hybrid health record evironment

source systems

refer to other computer systems that feed information into the EHR, which would also need to be corrected according to policy when corrections are made in the EHR.

What is an Enterprise Master Patient index (EMPI)?

references all patients in two or more facilities (ie integrated healthcare delivery system or health information exchange (HIE).

Connectivity

refers to the capacity of health records systems to provide electronic communication linkages and allow the exchange of health record data among information systems

Confidentiality

refers to the expectation that the personal information shared by an individual is to be used only for its intended purpose.

National Cancer Registrars Assoc.

represents cancer registrar professionals. Their mission is to serve as the premier education, credentialing and advocacy for cancer data professionals.

Privacy Rule

requires providers whom provide direct patient care to secure the patient's written acknowledge that they have received the providers notice of privacy practices.

Data granularity

requires that the attributes of data and values of data be defined at the correct level of detail for the intended use of the data.

Other HIM functions

research, statistical reporting, cancer registries, trauma registries, and birth certificates

Which term indicates that a document has been removed from standard view?

retraction

3 types of information for authentication

something you know, something you have, or something you are. most common is the use of user names and passwords. Also Biometrics and access cards

paper records

source-orientated health record - organizes information according to the department using it; problem orientated - all information related to each clinical problem is kept together. Integrated - information is listed in chronological order.

fixed rules that must be followed for every form

standards

HIMs most important functions

storage and retrieval of patient information. Additional functions managed: Research and statistics, Cancer and/or trauma registries, and Birth certificate completion

What are the most fundamental responsibilities of most HIM departments?

storage and retrieval, record processing, record completion, transcription, release of information (ROI), and clinical coding

Care Plan

summary of the patient's problems from the nurse or other professionals perspective with a detailed plan for interventions.

Electronic Document Management System

technologies used to provide portions of an electronic health record and does more than manage documents after they are scanned..In a hybrid record environment, the document imaging component is often used to make paper-based records electronically accessible post-discharge.

Gov. Licensing Agencies

the goal of local, state and federal licensing agencies is to make sure that the health care facilities in their areas provide effective and appropriate care to healthcare consumers.

abstracting

the process of extracting data from the health record and entering them into a computer database

Research

to develop new products; conduct clinical research; assess technology; study patient outcomes; effectiveness and cost-effectiveness of patient care; identify populations at risk; develop registries and databases; assess the cost effectiveness of record systems

goal of hybrid record system

to enable retrieval of information to assist healthcare professionals in providing quality patient care and reporting patient outcomes.

What is the purpose of an HIE organization?

to increase the availability of health information to authorized stakeholders in order to improve quality and safety of healthcare delivery across the continuum.

Functionality of EHR

varies depending on the system used. refers to features in the EHR that allow the user to maintain different versions of a document, track changes made to a document, lock a document from changes, and create user profiles that limit who may edit entries and so forth. The ability to unlock a record should be given to only a few individuals and typically this would be the health information manager. The HIM professional must track changes to the health record and assure appropriate follow-up in any source systems or other data repositories.

What controls which version of the document will be viewable within the health record?

version control - example one unsigned and one signed - documents must be flagged when an earlier version of a document exists and the date and time of the availability of each version of the document must be clearly documented.

Advance directive

written document that provides directions about a patient's desires in relation to care decisions for use by health care workers if the patient is unable to communicate. Living will and durable power of attorney.