CCA 1

EHR

CPOE - computerized physician order entry systems CDS - clinical decision support system

Correcting errors in paper records

Draw a line in ink through incorrect entry and print the word "error" at the top with legal signature, date, time, and reason for change ERRORS MUST NEVER BE OBLITERATED. CHRONOLOGICAL ORDER. late entries should be noted

integrity

authentic, complete we can trust the information in the record. someone can't change the information

EOB

explanation of benefits to patient

paper thinning

occurs for paper based record keeping in long term and is kept somewhere else and should always be accessible when needed

concurrent review

occurs while patient is still in the hospital

OIG

office of the inspector general -protect the integrity of the Health and Human Services and programs -commitment of compliance - chief compliance officer

for profit ACA

requires health care insuanace companies report the amount of premium revenue it collects that is spend on clinical services and quality improvement known as the MLR (medical loss ration)

RAI

resident assessment instrument

Skilled nursing facilities care plan

resident assessment instrument (RAI) based on MDS -minimum data set for long term CAA- care area assessments Medicare uses this to determine reimbursement RAI submitted electronically to health department, than CMS

Utilization Management

reviews concurrently admission, continued care, and discharged

acute

short term

CDI -interdisciplinary collaboration

should have a mix of professionals nurses, physician, risk managemet, finance, HIM

SOAP

subjective objective assessment plan

goal of CDI

to initiate concurrent and appropriate, retrospective reviews of health records for conflicting, completing, or non specific provider documentation

retrospective review

occurs after patient discharged

problem oriented health record

1970s

All entries in the health record should be permanent

All entries in the health record should be permanent

Managed Care Plans

HMO- health maintanance organiztions PPO - preferred provider organiztions POS - point of service

National Committee for Quality Assurance

NCQA not for profit mission is to improve healthcare quality by accrediting, assessing, and reporting the quality of managed care plans CMS- Centers for Medicare and Medicaid Services

autopsy

National Association of Medical Examiners pathologist

When errors in the EHR are corrected, the erroneous information should not be displayed, but there should be a way to view the previous version of the document with the original data

When errors in the EHR are corrected, the erroneous information should not be displayed, but there should be a way to view the previous version of the document with the original data

corrections by patients should be added as an addendum

addendum . ...separate note

charge description master (CDM)

also known as chargemaster

registration forms

also known as face sheet

transfer record

also known as referral record

APGAR

appearance , pulse, grimace, activity , respiratory

patient management software

business information

birthday rule

child who has the parent with the first birthday mom - may 10 dad - october 10 mom first

Records must be

complete, legible, time stamp, dated, author of entry, authenticated

reliability

consistency

CO-OPs part of ACA

consumer operated and oriented plans non for profit , low interest loans to provide insurance coverage

accuracy

correctness

coordination of benefits (COB)

deciding which insurance pays first if there is more than one insurance

Administrative data

demographic data

authorizations

form required under HIPPA for use and disclosure of protected health information

expressed consent, implied consent, informed consent

given orally or written consent sticking your hand out for blood pressure physician explains everything and gives options

CMS condistions of coverage

govern ambulatory surgical centers and those who see medicare reimbursement

CMS

has guidelines on authentication

auto-authentication

if a physician dictated a note for an operative procedure and automatically signs because he performed it....but does not check for accuracy or errors.... this method does not meet guidelines and should not be used.

NPP

notice of privacy practices

comprehensive and centralized data helps

keeping administrative, inpatient and outpatient information together

chronic

long term , diabetes

flow records

monitors chronological info ...vitals, trends over time, fluid intake and output

History and Physical

must be completed within 24 hours of admission

benchmarks

one's own results against others results performance improvement

Both CDI professionals and physicians must be senders and receivers

open- ended questions

standing orders

orders the medical staff or an individual physician established as routine care for a specific diagnosis or procedure.

PFSH

past, family, social, history

first party second party third party

patient provider health insurance

AMA

patient leaves AGAINST MEDICAL ADVICE

physician champion

physician champion

PAI

rehab patient assessment instrument facilities accredited through CARF - commission on accreditation of rehabilitation facilities

RA

remittance advice to provider