Chapter 3 - Content and Structure of Health Record

A patients legal status, complaints of others regarding the patient, and reports of restraints or seclusions would be found most frequently in which type of health record?

Behavioral health

Which group focuses on accreditation of rehabilitation programs and services

CARF

Which standardized tool is used to assess Medicare- certified rehabilitation facilities?

Care area assessment (CAA)

Medical history

Documents of patients past and present complaints and systems, patients family history and personal history. Includes a description of the physician's review of body systems

Clinical data

Documents the patients medical Collection begins before admission Admitting diagnosis

End-stage renal disease services documentation

Standards include criteria for record content as well as for record keeping, including patients rights, assessment and plan of care.

The patient indicates that her pain is worse. In which part of SOAP note would this information be recorded?

Subjective

problem list

a list of illnesses, injuries, and other factors that affect the health of an individual patient, usually identifying the time of occurrence or identification and resolution

physical examination report

a physicians documented findings based on his assessment. When assessing a patient's body systems

Accreditation Commission for Health Care (ACHC)

a private nonprofit accreditation organization offering accreditation services for home health, hospice, and alternate site healthcare such as infusion nursing, and home/DME supplies

Record thinning

a process used to store excess old records used in a paper based records in long term facilities

transfer record

a review of the patient's acute stay along with current status, discharge and transfer orders, that accompanies the patient when he is transferred to another facility; referral form

patient history questionnaire

a series of structured questions to be answered by patients to provide information to clinicians about their current health status

In a problem-oriented health record, problems are organized by?

a special number

Outcomes and Assessment Information Set (OASIS)

a standard core assessment data tool developed to measure the outcomes of adult patients receiving home health services under the Medicare and Medicaid programs

Patient Assessment Instrument (PAI)

a standardized tool used to evaluate the patient's condition after admission to, and at discharge from the Rehabilitation healthcare facility for inpatients and reimbursed by medicare. CORF is used for outpatient rehabilitation programs.

discharge summary

a summary of a patients stay in a hospital that must be signed by the attending physician.

care plan

a summary of the patients problems from the nurse or other professionals perspective with a detailed plan for intervention. Includes notes on admissions, discharge notes and the PT condition during intervals throughout the patients stay.

integrated health record (integrated health record format)

a system of health record organization in which all the paper forms are arranged in strict chronological order and mixed with forms created by different departments

source-oriented health record (source-oriented health record format)

a system of health record organization in which information is arranged according to the patient care department that provided the care

pathology report

a type of health record or documentation that describes the results of a microscopic and macroscopic evaluation of a specimen removed or expelled during a surgical procedure

palliative care

a type of medical care designed to relieve the patient's pain and suffering without attempting to cure the underlying disease

Resident Assessment Instrument (RAI)

a uniform assessment instrument developed by CMS to standardize the collection of skilled nursing facility patient data; includes MDS 3.0, triggers, and care area assessments (CAA)

accreditation

a voluntary process that a facility has made in meeting the standards of independent accrediting organization.

Interdisciplinary teams

establishes a plan of care for hospice patients required by federal regulations

Written or spoken permission to proceed with care is classified as?

expressed consent

Correctional facilities documentation of services

includes a history and physical, a chest x-ray, lab testing, dental exam and psychological evaluations. may choose to comply with the joint commission, the American correctional association or national commission of correctional health care.

expressed consent

spoken or written permission granted by a patient to a healthcare provider that allows the provider to perform medical or surgical services

Which group focuses on accreditation of managed care?

National committee for quality assurance

Sleeping patterns, head and chest measurements, feeding and elimination status, weight, apgar scores are recorded in which of the following records?

Newborn

Registration record

Documents demographic information about the patient.

Which is true of paper based records?

They are susceptible to damage fro fire and floods.

CDI Clinical documentation improvement

A form established by AHIMA CDI TOOLKIT in review form or to clarifying form to identify, clarify missing information, document accurate diagnostic and procedural codes, provide education and appropriate third party reimbursements while a patient is in many health care settings.

Accreditation Association for Ambulatory Health Care (AAAHC)

Accredits ambulatory settings Documentation standards emphasize summaries for enhancing continuity of care

Commission on Accreditation of Rehabilitation Facilities (CARF)

Accredits rehabilitation programs and services within other health care organizations

What two major types of data are contained in the health record?

Administrative and clinical

Which administrative documents provides information on the patients desires for healthcare for use if he/she in incapacitated?

Advance directives

Patient history questionnaire, problem lists, diagnostic test results, and immunization records are commonly found in which type of record?

Ambulatory care

problem-oriented health record

An itemized grouped list of the patients past and present social, psychological, and medical problems, by the problem and its initial care plan and the progress notes made by the physician that is identified by a unique number within the patients file. May also use "SOAP"

Computer-based Patient Record (CPR)

Computer Patient Record. A health record that is used by allowing healthcare professionals to document reports in real time decision making and for the patient to access to those decisions.

Which is an accrediting organization?

DNV (Det Norske Veritas Healthcare)

Diagnostic and therapeutic procedures

Describes the physicians performed evaluation and gives the names of clinicians and other providers to which a patient should follow up on: includes findings on x-rays, mammogams, ultrasounds, scans, lab tests, and other diagnostic procedures from admission to discharges.

Integrated health record

Documentation from various sources that are filed together in chronological order. Great when following the patients diagnosis and treatment. Bad when trying to compare notes with other physicians notes.

Rehabilitation services documentation

Documentation requirements for rehab vary because facilities range from comprehensive inpatient care to outpatient or special programs. accredited through CARF, Joint Commission or AOA.

Patients instructions

Documented instructions for following up with another physician.

Consultation reports

Documented opinions about a patients condition given by providers other than the attending physicians.

Consents, authorizations, and acknowledgments

Documented patients agreement to undergo treatment, permission to release confidential information or the recognition that the information has been received.

electronic health record (EHR)

Electronic Health Record (EHR) A health record that is used by allowing healthcare professionals to communicate effectively and document reports in real time decision making within the clinical setting.

A definition of what constitutes a record, recording where each component is located, and noting dates of format changes are particularly important in:

Electronic records

Which type of health record contains information about care provided prior to arrival at a healthcare setting and documentation of care provided to stabilize the patient?

Emergency care

Interdisciplinary care plans are an important part of which type of health record?

End-stage renal disease

certification standards

Government reimbursement program standards that are applied to facilities that choose to participate in federal programs such as medicare and Medicaid. such A COp and COC

Conditions for Participation (CoP)

Guidelines and regulations set by cms under which facilities are allowed to take part in the Medicare and Medicaid programs.

The ambulatory surgery record contains information most similar to:

Hospital operative records

Which type of health record includes both paper and electronic components?

Hybrid

Which electronic record technological capabilities would allow an x-ray to be sent to a physician in another state?

Image processing

In an integrated health record, documentation by health professionals is organized by..

In section by problem number

Administrative Data

Includes demographics and financial information as well as various contents and authorizations related to the provision of care and the handling of confidential patient information.

Diagnostic procedures

Lab tests (urine, blood, other samples) pathologic exams ( tissue and organ samples removed) Imaging (scans, x-rays, ultrasounds, MRI's and PET's) Monitor and tracings of body functions

Which of the two terms refer to state or county regulations that healthcare facilities must meet to be permitted to provide care?

Licensure

Paper records may require thinning in which two settings?

Long-term care and correctional care

licensure requirements

Medical practice must be licensed by the government such as the state or county and must maintain that license if continuing practice as long as they are providing care.

Informed consent

Patient signed consent after the physician has explained and given the chance to ask questions.

A growth and development record may be found in what type or record?

Pediatric

The document that indicates current and past medical conditions is:

Problem list

Palliative Care

Provided by hospice in the care management of a pt pain and provides supportive services to comfort the patients an their families

Clinical observations

Provides clinical summaries of the patients illnesses and treatment documented by physicians, nurses and allied health professionals. (usually provided in acute care hospitals in progress notes)

Which is a disadvantage of an EHR over a paper-based record?

Requires privacy and security measures

Soap

Subjective (patients own words problem list), Objective (factual info like: lab work and physicians findings), and assessment (complete framework of physicians order for treatment that the physicians use) plan to format the patients oriented progress notes.

Acute healthcare records documentation

The intensive and critical care services, documented patient information that is used for other health care settings and are found in paper, hybrid and electronic records.

Which accreditation organizations provide standards for the widest variety of healthcare facilities?

The joint commission

Battery

The unlawful touching of a patient without his/her informed or implied consent

An accredited organization is rewarded deemed status by medicare for one of its programs. This means that facilities receiving accreditation under its guidelines do not need to:

Undergo accreditation surveys

physician's orders

a documented physician's instructions to other parties who actually perform diagnostic tests and treatments, administer medications and provide specific services.

operative report

a formal document that describes the events surrounding a surgical procedure or operation and identifies the principal participants in the surgery

Community Health Accreditation Program (CHAP)

a group that surveys and accredits both home healthcare and hospice organizations

Commission for the Accreditation of Birth Centers (CABC)

a group that surveys and accredits freestanding birth centers

hybrid record

a health record that includes both paper and electronic elements

advance directive

a legal written document that provides directions abut a patients desires in relation to care decisions for use by healthcare workers if the patient is incapacitated or not able to communicate. ex: advance directive, living wil

National Committee for Quality Assurance (NCQA)

accreditation organization whose standards focus on patient safety, confidentiality, consumer protection. proof of accreditation depends on the outcome of the patients care and the services provided.

Medicare Conditions of Participation or Conditions for Coverage

administered by the federal government describes the requirements that healthcare organizations must meet to receive reimbursement for services provided to Medicare beneficiaries

What is not considered patient demographic information?

admitting diagnosis

National Commission on Correctional Health Care (NCCHC)

an accreditation organization that maintains comprehensive standards for healthcare in correctional facilities throughout the US

SOAP (Subjective, Objective, Assessment, Plan)

an acronym for a component of the problem-oriented medical record that refers to how each progress note contains documentation relative to subjective observations, objective observations, assessments, and plans

authorization to disclose information

an authorization that allows the healthcare facility to verbally disclose or send health information to other organizations (see authorization)other than treatment, payment, or healthcare operations.

electronic medical record (EMR)

an electronic record of health-related information on an individual that can be created, gathered, managed, and consulted by authorized clinicians and staff.

personal health record (PHR)

an electronic record of health-related information on an individual that conforms to nationally recognized interoperability standards that can be drawn from multiple sources while being managed and controlled by the individual

DNV (Det Norske Veritas)

an independent international organization that began offering hospital accreditation services in the US in 2008

deemed status

an official healthcare facility is in compliance with the Medicare Conditions of Participation; must be accredited by the JC or AOA

American Correctional Association (ACA)

an organization that developed basic accreditation standards for healthcare in correctional facilities

American Association for Accreditation of Ambulatory Surgery Facilities (AAAASF)

an organization that sets standards for accrediting ambulatory surgical facilities

Who make preoperative notes?

anesthesiologist and surgeons prior to a procedure

Which specialized type of progress note provides healthcare professionals impressions of the patient problems with detailed treatment action steps?

care plan

Conditions for Coverage (CoC)

certification standards: government reimbursement program applied to facilities that choose to participate in federal government reimbursement programs such as Medicare and Medicaid

imaging technology

computer software designed to combine health record text files with diagnostic imaging files

An attending physician requests the advice of a second physician who then reviews the health record and examines the patient. The second physician records impressions in what type of report?

consultation

Behavioral healthcare docs

delivered in inpatient hospitals, outpatient clinics, physicians offices, rehabilitation programs, long term care facilities and community mental health programs. accreditation by (CARF) and AOA supports in behavioral health and with patients with disabilities.

consultation report

health record documentation that describes the findings and recommendations of consulting physicians not attending physicians. Consulting physicians use dictations to report findings.

Portions of a treatment record may be maintained in a patients home in which two types of settings?

home health and hospice

Pediatric care documents

includes ambulatory records as well as birth history, nutritional history, personal, social and family history, growth and development records, immunizations, well child visits and medical concerns, medications taken

recovery room report

includes post-anesthesia notes, nurses notes regarding the patients condition and surgical site, vital signs and intravenous fluids and other monitoring after a surgical procedure.

consent to treatment

legal permission given by a patient or a patient's legal representative to a healthcare provider that allows the provider to adminster care and/or treatment or to perform surgery and/or other medical procedures

Hospice Care docs

located in homes, hospitals, free standing facilities and long term care. offers palliative care

Standing orders

orders that a medical staff or individual doctor has established a routine care for a specific diagnosis or procedure.

The Joint Commission (JC)

organization that provides standards for the widest variety of healthcare facilities. ex. a list of abbreviations not to be used in the patients health care records.

Which of the following reports provides information on tissue removed during a procedure?

pathology

When tissue is removed for evaluation it is called?

pathology report

medical staff privileges

permission that is granted by medical staff to enter progress notes I the health record. usually the PT attending physician, consulting physician, house medical staff, nurses, nutritionists, social workers, and clinical therapists.

What do nurses report?

preoperative patient preporations

care area assessments (CAA)

reflect conditions, symptoms and areas of concern; Interpreting and addressing CAAs is basis for the development of individualized care plan

Long term care docs

reg forms and id personal property list hospital records including physical and history advance directives clinical assessments RAI/MDS and care plans physicians orders physicians progress notes/consultation nursing notes rehabilitation therapy notes social services, nutritional services and activities doc medication and records of monitors labs, radiology and special reports discharge or transfer documentation

Home health docs

regulated by the state licensure regulations. organizations such as the joint commission, community health accreditation program, and the accreditation commission community health care (ACHC) and medicare home health certification/plan of care (OASIS).

Centers for Medicare and Medicaid Services (CMS)

the division of the Department of Health and Human Services that is responsible for developing healthcare policy in the US and for administering the Medicare program and the federal portion of the Medicaid program

progress notes

the documentation of clinical observations of a patient's care, treatment, and therapeutic response that is entered into the health record n chronological order of the patients condition and the response to that treatment during a hospital stay.

Patient Self-Determination Act (PSDA)

the federal legislation that requires healthcare facilities to provide written information on the patient's right to issue advance directives and to accept or refuse medical treatment. hospitals that accept medicare and Medicaid are required to follow these provisions.

Minimum Data Set (MDS) for Long-Term Care

the instrument specified by CMS that requires nursing facilities to conduct a comprehensive, accurate, standardized, reproducible assessment of each resident's functional capacity

American Osteopathic Association (AOA)

the professional association of osteopathic physicians, surgeons, residency programs for doctors of osteopathy that inspects and accredits osteopathic colleges and hospitals

Patient's bill of rights

the protections afforded to individuals who are undergoing medical procedures in hospitals or other healthcare facilities; also referred to as patient rights

anesthesia report

the report that notes any preoperative medication and response to it, the anesthesia administered with dose and method of administration, the duration of administration, the patient's vital signs while under anesthesia, and any additional products given the patient during a procedure

implied consent

the type of permission that is inferred when a patient voluntarily submits to treatment

Source-oriented health record

the way a patients documents are grouped together in chronological order by date according to their lab records, radiology records and physicians clinical notes. Time consuming to someone who is trying to get the overall picture of the patients care..

consent

used for the permission is for treatment, payment or healthcare operations.

Ambulatory surgical care document

used in free standing or hospital based settings and are regulations required by Medicare.

Which will not be found in a medical history?

vital signs

autopsy report

written documentation of the findings from a postmortem pathological examination