. Chapter 2 - Purpose and Function of the Health Record
CMS
Centers for Medicare and Medicaid Services
Examples of patient care delivery usage of the medical record includes which of the following uses?
Communication between caregivers
We had 324 Medicare patients last month. This statement represents what?
Data
According to the AHIMA data quality model, what is the term that is used to describe how data is translated into information?
Data analysis
What is aggregate data?
Data extracted from individual health records and combined to form de-identified information about groups of patients that can be compared and analyzed
Difference between data and information
Data represents facts. Information represents meaning.
True or false: A physical therapist documenting in the health record is an institutional health record user
F
True or false: An auditor who is employed by Medicare is reviewing a health record for a mortality study. This auditor is an individual health record user.
F
True or false: CMS uses data to accredit hospitals.
F
True or false: Patients do not have the right to add missing information to the health record.
F
True or false: The lab test "hemoglobin: 14.6 gm/110 ml" is considered information.
F
Use of the health record to the study the effectiveness of a given drug is considered a primary use of the health record.
F
NCVHS
National Committee on Vital and Health Statistics
hybrid health record
a combination of paper and electronic records
What are the attributes associated with the storage function of health care records?
quality, accessibility, security, flexibility, connectivity and efficiency
I work for CMS. How would I use the health record? A. Make decisions on healthcare reimbursement B. Medical research C. Issuing hospital and medical staff licenses D. Accrediting healthcare organizations
A. Make decisions on healthcare reimbursement
Act signed in 2009 that accelerated EHR adoption
American Recovery and Reinvestment Act (ARRA), an economic stimulus package that provides reimbursement incentives to providers and hospitals that are "meaningful" users of certified EHR technology
EHR
An electronic record of health-related information on an individual that conforms to nationally recognized interoperability standards and that can be created, managed, and consulted by authorized clinicians and staff across more than one healthcare organization
Submitting health record documentation to a third-party payer for the purpose of substantiating a patient bill is considered a secondary purpose of the health record.
F
What major healthcare legislation was passed in 1996?
Health Insurance Portability and Accountability Act (HIPAA) of 1996
IOM
Institute of Medicine
NHIN
National Health Information Network
ONC
Office of the National Coordinator for Health Information Technology
I am a patient. My medical history including information from myself and my physicians is stored on the Internet. This is an example of which of the following:
PHR
Which of the following is an example of a primary purpose of the medical record?
Patient care management
Which of the following users would utilize aggregate data?
Patient care managers and support staff
PHR
Personal Health Record - a health record initiated and maintained by an individual.
Primary purposes of health record
Relate directly to the provision of patient care services as well as the documentation of the patient's health status: Patient care delivery Patient care management Patient care support processes Financial and other administrative processes Patient self-management
Secondary purposes of the health record
Relate to the environment in which patient care is provided - they are not related directly to specific patient care encounters: Education Regulation Research Public health and homeland security Policy making and support Industry
I work for an organization that utilizes health record data to prove or disprove hypotheses related to disease. I must work for what type of organization?
Research
True or false: A researcher uses data to determine the recommended treatment.
T
True or false: The health record is the principal repository for data and information about the healthcare services provided to individual patients.
T
True or false: The primary purposes of the health record are associated directly with the provision of patient care services as well as the documentation of the patient's health status.
T
health record
The principal repository for data and information about the healthcare services provided to an individual patient
What is an example of institutional users of the health record ?
Third-party payer
What laws were passed that allowed law enforcement more access to health records?
USA Patriot Act (2001) and The Homeland Security Act (2002)
What are the quality characteristics applied to the four quality management domains?
accuracy accessibility comprehensiveness consistency currency definition granularity precision relevancy timeliness
Primary users of health records
clinical professionals who provide direct patient care
Secondary users of health records
healthcare managers and administrators, government agencies and policy makers, third-party payers, researchers, educators, accreditation organizations
data definition
means that the data and information documented in the health record are defined. Users of the data must understand what the data mean and represent.
data accuracy
means that the data are correct. The data should represent what was intended or defined by the original source of data.
data accessibility
means that the date are easily obtainable. Authorized users of the health record must be able to access information easily when and where they need it.
Three types of formats are commonly used in paper-based record systems:
source-oriented problem-oriented integrated
The primary function of the health record is to
store patient care documentation
Are the PHR and EHR synonymous.?
the PHR is controlled by the patient and the EHR is controlled by health care providers.
clinical decision support
the process in which individual data elements are represented in the computer by special code to be used in making comparisons, trending results and supplying clinical reminders and alerts
