Documentation for Health Records

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Acute care

Medical care of a limited duration that is provided in an inpatient hospital setting to diagnose and/or treat an injury or a short-term illness

Joint Commission on Accreditation of Healthcare Organizations (JCAHO)

Name used for Joint Commission on Accreditation of Hospitals when it began to accredit more nonhospital healthcare settings in 1987; now known as The Joint Commission

Subacute care

A type of step-down care provided after a patient is released from an acute care hospital (including nursing homes and other facilities that provide medical care, but not surgical or emergency care)

Hybrid health record

A combination of paper and electronic records; a health record that includes both paper and electronic elements

Allied health professional

A credentialed healthcare worker who is not a physician, nurse, psychologist, or pharmacist (for example, a physical therapist, dietitian, social worker, or occupational therapist)

Secondary care

A general term for healthcare services provided by a specialist at the request of the primary care physician

Legal health record

Documents and data elements that a healthcare provider may include in response to legally permissible requests for patient information

Diagnostic code

Numeric or alphanumeric characters used to classify and report diseases, conditions, and injuries

Continuous quality improvement (CQI)

1. A management philosophy that empha- sizes the importance of knowing and meeting customer expectations, reducing variation within processes, and relying on data to build knowledge for process improvement 2. A component of total quality management (TQM) that emphasizes ongoing performance assessment and improvement planning

Complications

1. A medical condition that arises during an inpatient hospitalization (for example, a postoperative wound infection) 2. Condition that arises during the hospital stay that prolongs the length of stay at least one day in approximately 75 percent of the cases (as in complication and comorbidity [CC])

Comorbiditie

1. A medical condition that coexists with the primary cause for hospitalization and affects the patient's treatment and length of stay 2. Pre-existing condition that, because of its presence with a specific diagnosis, causes an increase in length of stay by at least one day in approximately 75 percent of the cases (as in complication and comorbidity [CC])

Accreditation

1. A voluntary process of institutional or organizational review in which a quasi-independent body created for this purpose periodically evaluates the quality of the entity's work against preestablished written criteria 2. A determination by an accredit- ing body that an eligible organization, network, program, group, or individual complies with applicable standards 3. The act of granting approval to a healthcare organization based on whether the organization has met a set of voluntary standards developed by an accreditation agency

Critical-access hospital

1. Hospitals that are excluded from the outpatient prospective payment system because they are paid under a reasonable cost-based system as required under section 1834(g) of the Social Security Act 2. Small facilities that give limited outpatient and inpatient hospital services to people in rural areas

Health record

1. Information relating to the physical or mental health or condition of an individual, as made by or on behalf of a health professional in connection with the care ascribed that individual 2. A medical record, health record, or medical chart that is a systematic documentation of a patient's medical history and care

Case management

1. The ongoing, concurrent review performed by clinical professionals to ensure the necessity and effectiveness of the clinical services being provided to a patient 2. A process that integrates and coordinates patient care over time and across multiple sites and providers, especially in complex and high-cost cases, with goals of continuity of care, cost-effectiveness, quality, and appropriate utilization 3. The process of developing a specific care plan for a patient that serves as a communication tool to improve quality of care and reduce cost

Certification

1. The process by which a duly authorized body evaluates and recognizes an individual, institution, or educational program as meeting predetermined require- ments 2. An evaluation performed to establish the extent to which a particular com- puter system, network design, or application implementation meets a prespecified set of requirements

Retention

1.Mechanisms for storing records, providing for timely retrieval, and establishing the length of times that various types of records will be retained by the healthcare organization 2. The ability to keep valuable employees from seeking employment elsewhere

Certificate of destruction

A document that constitutes proof that a health record was destroyed and that includes the method of destruction, the signature of the person responsible for destruction, and inclusive dates for destruction

Health Care and Education Reconciliation Act

A federal law enacted by Congress through reconciliation in order to make changes to the Patient Protection and Affordable Care Act. HCERA was signed into law by President Barack Obama on March 30, 2010; Also called HR 4872

Patient Protection and Affordable Care Act (PPACA)

A federal statute that was signed into law on March 23, 2010. Along with the Health Care and Education Reconciliation Act of 2010 (signed into law on March 30, 2010), the Act is the product of the healthcare reform agenda of the Democratic 111th Congress and the Obama administration

Medicare

A federally funded health program established in 1965 to assist with the med- ical care costs of Americans 65 years of age and older as well as other individuals entitled to Social Security benefits owing to their disabilities

Behavioral healthcare

A broad array of psychiatric services provided in acute, long- term, and ambulatory care settings; includes treatment of mental disorders, chemical dependency, mental retardation, and developmental disabilities, as well as cognitive re- habilitation services

Medical specialties

A group of clinical specialties that concentrates on the provision of nonsurgical care by physicians who have received advanced training in internal medi- cine, pediatrics, cardiology, endocrinology, psychiatry, oncology, nephrology, neurology, pulmonology, gastroenterology, dermatology, radiology, and nuclear medicine, among many other concentrations

Surgical specialties

A group of clinical specialties that concentrates on the provision of surgical services by physicians who have received advanced training in obstetrics and gynecology, ophthalmology, orthopedics, cardiovascular surgery, otorhinolaryngology, trauma surgery, neurosurgery, thoracic surgery, urology, plastic and reconstructive surgery, anesthesiology, and pathology

Centers for Disease Control and Prevention (CDC)

A group of federal agencies that oversee health promotion and disease control and prevention activities in the United States

Integrated healthcare network

A group of healthcare organizations that collectively provides a full range of coordinated healthcare services ranging from simple preventative care to complex surgical care

Regional health information organization (RHIO)

A health information organization that brings together healthcare stakeholders within a defined geographic area and governs health information exchange among them for the purpose of improving health and care in the community

Confidentiality

A legal and ethical concept that establishes the healthcare provider's responsibility for protecting health records and other personal and private information from unauthorized use or disclosure

Case-mix analysis

A method of analyzing health records by grouping patients according to a predefined set of characteristics; used to determine Medicare reimbursements

National Council for Prescription Drug Programs (NCPDP)

A not-for-profit ANSI- accredited standards development organization founded in 1977 that develops standards for exchanging prescription and payment information

Inpatient

A patient who is provided with room, board, and continuous general nursing services in an area of an acute care facility where patients generally stay at least overnight

Outpatient

A patient who receives ambulatory care services in a hospital-based clinic or department

Longitudinal health record

A permanent, coordinated patient record of significant information listed in chronological order and maintained across time, ideally from birth to death

National Quality Forum (NQF)

A private, not-for-profit membership organization created to develop and implement a nationwide strategy to improve the measurement and report- ing of healthcare quality

Joint Commission

A private, voluntary, not-for-profit organization that evaluates and accredits hospitals and other healthcare organizations on the basis of predefined performance standards; formerly known as the Joint Commission on Accreditation of Healthcare Organizations or JCAHO

Accreditation organization

A professional organization that establishes the standards against which healthcare organizations are measured and conducts periodic assessments of the performance of individual healthcare organizations

National Committee on Vital and Health Statistics (NCVHS)

A public policy advisory board that recommends policy to the National Center for Health Statistics and other health-related federal programs

Peer Review Act

A regulation enacted in 1982 to monitor the quality of care provided and the medical necessity of services

Prospective Payment Act

A regulation enacted in 1982 to monitor the quality of care provided and the medical necessity of services

Healthcare Quality Improvement Act

A regulation enacted in 1986 to monitor the quality of care provided and the medical necessity of services

Mental Health Parity Act (MHPA)

A regulation enacted in 1996 to monitor the quality of care provided and the medical necessity of services

Telemedicine

A telecommunications system that links healthcare organizations and patients from diverse geographic locations and transmits text and images for (medical) consultation and treatment; Also called telehealth

Diagnosis-related group (DRG)

A unit of case-mix classification adopted by the federal government and some other payers as a prospective payment mechanism for hospital inpatients in which diseases are placed into groups because related diseases and treatments tend to consume similar amounts of healthcare resources and incur similar amounts of cost; in the Medicare and Medicaid programs, one of more than 500 diagnos- tic classifications in which cases demonstrate similar resource consumption and length- of-stay patterns. Under the prospective payment system (PPS), hospitals are paid a set fee for treating patients in a single DRG category, regardless of the actual cost of care for the individual

Covered entities

Any healthcare provider or contractor that transmits individually identifiable health information in electronic form

Working document

Administrative information that should not be considered part of the legal health record and should not be produced in response to a court order, subpoena, or request for the health record

Personal health record (PHR)

An electronic or paper health record maintained and updated by an individual for himself or herself; a tool that individuals can use to collect, track, and share past and current information about their health or the health of someone in their care

Computer-based patient record (CPR)

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; Also called electronic health record

Medicaid

An entitlement program that oversees medical assistance for individuals and families with low incomes and limited resources; jointly funded between state and fed- eral governments and legislated by the Social Security Act

Certification Commission for Healthcare Information Technology (CCHIT)

An in- dependent, voluntary, private-sector initiative organized as a limited liability corporation that has been awarded a contract by the US Department of Health and Human Services (HHS) to develop, create prototypes for, and evaluate the certification criteria and inspection process for electronic health record products (EHRs)

Picture archiving and communications system (PACS)

An integrated computer system that obtains, stores, retrieves, and displays digital images (in healthcare, radiological images)

Health Level Seven (HL7)

An international organization of healthcare professionals dedicated to creating standards for the exchange, management, and integration of electronic information

Court order

An official direction issued by a court judge and requiring or forbidding specific parties to perform specific actions

Accountable care organization (ACO

An organization of healthcare providers ac- countable for the quality, cost, and overall care of Medicare beneficiaries who are assigned and enrolled in the traditional fee-for-service program

Health Information Exchange Organization (HIO)

An organization that supports, oversees, or governs the exchange of health-related information among organizations according to nationally recognized standards

American Recovery and Reinvestment Act (ARRA)

Aneconomicstimuluspack- age enacted by the 111th United States Congress in February 2009; signed into law by President Obama on February 17th, 2009; an unprecedented effort to jumpstart the econ- omy, create/save millions of jobs, and put a down payment on addressing long-neglected challenges; an extraordinary response to a crisis unlike any since the Great Depression; in- cludes measures to modernize our nation's infrastructure, enhance energy independence, expand educational opportunities, preserve and improve affordable health care, provide tax relief, and protect those in greatest need; Also called Recovery Act; Stimulus

Advanced decision support

Automated clinical practice guidelines that are built in to electronic health record systems and designed to support clinical decision making

Tertiary care

Care centered on the provision of highly specialized and technologically advanced diagnostic and therapeutic services in inpatient and outpatient hospital settings

Derived data

Data that consist of factual details aggregated or summarized from a group of health records that provide no means to identify specific patients; it is not considered part of the legal health record though it has the same level of confidentiality

Office for Civil Rights (OCR)

Department in HHS responsible for enforcing civil rights laws that prohibit discrimination on the basis of race, color, national origin, disability, age, sex, and religion by healthcare and human services entities over which OCR has jurisdiction, such as state and local social and health services agencies, and hospitals, clinics, nursing homes, or other entities receiving federal financial assistance from HHS. This office also has the authority to ensure and enforce the HIPAA Privacy and Security Rules; OCR is responsible for investigating all alleged violations of the Privacy and Security Rules

Omnibus Budget Reconciliation Act (OBRA)

Federal legislation passed in 1987 that required the Health Care Financing Administration (now renamed the Centers for Medicare and Medicaid Services) to develop an assessment instrument (called the resident assessment instrument) to standardize the collection of patient data from skilled nursing facilities

Long-term care

Healthcare services provided in a nonacute care setting to chronically ill, aged, disabled, or mentally handicapped individuals

Health information management (HIM) professionals

Individuals who have received professional training at the associate or baccalaureate degree level in the management of health data and information flow throughout healthcare delivery systems; formerly known as medical record technicians or medical record administrators

Administrative information

Information used for administrative and healthcare opera- tions purposes, such as billing and quality oversight

Demographic data

Information used to identify an individual, such as name, address, gender, age, and other information linked to a specific person

Health Information Technology for Economic and Clinical Health Act (HITECH)

Legislation created to stimulate the adoption of EHR and supporting technology in the United States. Signed into law on February 17, 2009, as part of ARRA.

Hospitalist

Physicians employed by teaching hospitals to play the role that admitting physicians fulfill in hospitals that are not affiliated with medical training programs

Ambulatory care

Preventive or corrective healthcare services provided on a nonresident basis in a provider's office, clinic setting, or hospital outpatient setting

Joint Commission on Accreditation of Hospitals (JCAH)

Private, voluntary, not- for-profit organization formed in 1952 to accredit hospitals on the basis of predefined performance standards; now known as The Joint Commission.

e-discovery

Refers to Amendments to Federal Rules of Civil Procedure and Uniform Rules Relating to Discovery of Electronically Stored Information; wherein audit trails, the source code of the program, metadata, and any other electronic information that is not typically considered the legal health record is subject to motion for compulsory discovery

HITECH Act

See Health Information Technology for Economic and Clinical Health (HITECH)

Core measure

Standardized performance measures developed to improve the safety and quality of healthcare (for example, core measures are used in the Joint Commission's ORYX initiative)

Medicare severity-diagnosis related groups (MS-DRGs)

The US government's 2007 revision of the DRG system, the MS-DRG system better accounts for severity of illness and resource consumption; See also diagnosis-related group (DRG)

Destruction

The act of breaking down the components of a health record into pieces that can no longer be recognized as parts of the original record

Clinical privilege

The authorization granted by a healthcare organization's governing board to a member of the medical staff that enables the physician to provide patient services in the organization within specific practice limits

Primary care

The continuous and comprehensive care provided at first contact with the healthcare provider in an ambulatory care setting

Source-system data

The data from which interpretations, summaries, and notes are derived; examples include radiological film or scans, laboratory values, pathology slides, video and audio recordings, and EKG tracings

Data

The dates, numbers, images, symbols, letters, and words that represent basic facts and observations about people, processes, measurements, and conditions

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 United States and for administering the Medicare program and the federal portion of the Medicaid program and maintaining the procedure portion of the International Classifi- cation of Diseases, ninth revision, Clinical Modification (ICD-9-CM); called the Health Care Financing Administration (HCFA) prior to 2001

Health information exchange (HIE)

The exchange of health information electronically between providers and others with the same level of interoperability, such as labs and pharmacies

Corporate negligence

The failure of an organization to exercise the degree of care con- sidered reasonable under the circumstances that resulted in an unintended injury to an- other party

Health Insurance Portability and Accountability Act (HIPAA)

The federal legislation enacted to provide continuity of health coverage, control fraud and abuse in healthcare, reduce healthcare costs, and guarantee the security and privacy of health information; limits exclusion for pre-existing medical conditions, prohibits discrimina- tion against employees and dependents based on health status, guarantees availability of health insurance to small employers, and guarantees renewability of insurance to all em- ployees regardless of size; requires covered entities (most healthcare providers and orga- nizations) to transmit healthcare claims in a specific format and to develop, implement, and comply with the standards of the Privacy Rule and the Security Rule; and mandates that covered entities apply for and utilize national identifiers in HIPAA transactions; Also called the Kassebaum-Kennedy Law; Public Law 104-191

Tax Equity and Fiscal Responsibility Act of 1982 (TEFRA)

The federal legislation that modified Medicare's retrospective reimbursement system for inpatient hospital stays by requiring implementation of diagnosis-related groups and the acute care prospective payment system

Home healthcare

The medical and/or personal care provided to individuals and families in their places of residence with the goal of promoting, maintaining, or restoring health or minimizing the effects of disabilities and illnesses, including terminal illnesses

Long-term acute care

The medical care provided to individuals who are clinically complex and have multiple acute and chronic conditions requiring an average length of stay greater than 25 days in long-term care hospitals certified as acute care hospitals

Hospice care

The medical care provided to persons with life expectancies of six months or less who elect to forgo standard treatment of their illness and to receive only palliative care

Emergency and trauma care

The medical-surgical care provided to individuals whose injuries or illnesses require urgent care to address conditions that could be life threaten- ing or disabling if not treated immediately

Nationwide Health Information Network (NHIN)

The oldest and most successful example of intergovernmental data sharing in public health, and the shared relationships, standards, and procedures that form the mechanism by which NCHS collects and disseminates the nation's official vital statistics. These data are provided through contracts between NCHS and vital registration systems operated in the various jurisdictions and legally responsible for the registration of vital events—births, deaths, marriages, divorces, and fetal deaths

Release of information (ROI)

The process of disclosing patient-identifiable information from the health record to another party

Rehabilitation care

The process of restoring the disabled insured to maximum physical, mental, and vocational independence and productivity (commensurate with their limitations) through the identification and development of residual capabilities, job modifications, or retraining

Credentialing

The process of reviewing and validating the qualifications (degrees, licenses, and other credentials) of physicians and other licensed independent practitioners, for granting medical staff membership to provide patient care services

Biomedical research

The process of systematically investigating subjects related to the functioning of the human body

Release and disclosure

The processes that make health record information available to legitimate users

Skilled nursing care

The professional nursing care and related medical, therapeutic, psychosocial, and personal services provided in a residential setting to individuals recov- ering from injuries or illnesses or the residual effects of injuries or illnesses after the acute phase of the condition has resolved

Continuum of care

The range of healthcare services provided to patients, from routine ambulatory care to intensive acute care; the emphasis is on treating individual patients at the level of care required by their course of treatment with the assurance of communica- tion between caregivers

American College of Surgeons (ACS)

The scientific and educational association of surgeons formed to improve the quality of surgical care by setting high standards for surgical education and practice

Major diagnostic category (MDC)

Under diagnosis-related groups (DRGs), one of 25 categories based on single or multiple organ systems into which all diseases and dis- orders relating to that system are classified

Nationwide Health Information Network Exchange

demonstrates the ability to exchange health information on a national level.

Tethered record

sometimes also called a PHR, which is a subset of information compiled by the provider and offered to the consumer, often through the provider's website. A tethered record functions as a patient view into the provider's electronic record.

Untethered record

stresses patient control and the inclusion of information from multiple providers.


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