Health Information Management Technology, Chapter 7
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 dictate 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
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
What should be done when the HIM department's error or accuracy rate is deemed unacceptable?
A corrective action should be taken
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
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
Which of the following should be part of a comprehensive MPI maintenance program?
Advanced Person Search
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
Reviewing a health record for missing signatures and missing medical reports is called
Analysis
"Loose" reports are health record forms that:
Are received by the HIM department and added to the health record after it has been processed.
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
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.
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.
B Terminal digit filing
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
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.
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.
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
Assigning ICD-9-CM and CPT codes to the diagnosis and procedures documented in the medical record is called:
Clinical coding
What feature of the filing folder helps locate misfiles within the paper-based filing system?
Color coding
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.
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
Which of the following is a risk of copying and pasting?
Copying the note in the wrong patient's record.
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
Which of the following is an advantage of a centralized unit filing system?
One location in which to look for records
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
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
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.
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.
Specific performance expectations and/or structures and processes that provide detailed information for each Joint Commission standard are called:
Elements of Performance
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
Statements that define the performance expectations and/or structures or processes that must be in place are:
Standards
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.
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 requiements
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.
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.
Which of the following is used to locate an electronic health record
Health record number
One of the advantages of an EDMS is that it can:
Help manage work tasks
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.
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
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
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
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.
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.
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.
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.
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
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.
What type of paper-based storage conserves floor space by eliminating all but one or two aisles?
Mobile filing units
Under the False Claims Act, claims may be brought up to how many years?
No more than 7 years
measures limit an EHR's 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
In a paper-based system, the HIM department routinely delivers health records to:
Nursing units
What can function as a MPI?
Often the patient registration system aka registration, admission, discharge, and transfer system (R-ADT) functions as the MPI
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.
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
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.
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
A functionality of the electronic health record that allows patients access to their protected health information (for example, lab results) is:
Patient Portal
Record retention should be based on:
State regulations and AHIMA recommendations
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 doe the health record begin?
Patient registration
The computer system that may serve as the MPI function is the:
Patient registration system
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)
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.
Step by step instructions on how to complete a specific task are called:
Procedures
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
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
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
A chronological listing of data is called a/an?
Registry
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
Which of the following is a request from a clinical area to charge out a health record?
Requisition
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
Which of the following is an example of how the HIM professional interacts with the medical staff
Serves on medical staff committee
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
How do they ensure the integrity of patient identity in health information exchange
Standardization of health information exchange practices is paramount.
deemed status
TJC accredited hospitals are also deemed to be in compliance with the Medicare Conditions of Participation. - Medicare makes random surveys as well
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.
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"
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.
What dictates how the specific functions are carried out?
The medium in which the information is stored.
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.
What is the goal of the health record system?
To ensure that accurate information is available to authorized users to support quality patient care.
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
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.
Which term indicates that a document has been removed from standard view?
retraction
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
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.
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.
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
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.
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
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
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.
index
guide that serves as a pointer or indicator to locate something
general direction about the design of the form
guideline
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 involve ensuring inforamtion 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.
NONREPUDIATION measures
limit an EHR's user's ability to deny (repudiate) the origination, receipt, or authorization of a data exchange by that user" (ie signatures as example)
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.
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.
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
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. Purged records are often microfilmed, sent to off-site storage facilities or scanned.
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.
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 a certain that 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).
Other HIM functions
research, statistical reporting, cancer registries, trauma registries, and birth certificates
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
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
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.
abstracting
the process of extracting data from the health record and entering them into a computer database
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.
