Chap ?
  2. Two important functions of an HIM dept?
    • 1. maintain and
    • 2. Retrieve health information
  3. Two tools employed to facilitate maintainance and retrieval of health information are:
    • 1. The index
    • 2. The registry
  4. Def. of Index
    Def. of Registry
    Index: Anything that serves to guide, to point, or otherwise facilitate reference

    Registry: A formal or official recording of items, names or actions
  5. 5 types of Indexes?
    • 1. Master Patient Index
    • 2. Number index
    • 3. Disease index
    • 4. Operation index
    • 5. Physician's index
  6. What is the 1. Master Index (MPI)
    • Permanent record of all patients
    • The MPI is the key to locating patients records
    • List the numer associated with the name
    • MPI shoudl be retained forever
  7. Content of MPI (Master pateint index)
    • Full name
    • Address
    • indentifying number
    • SS number
    • DOB
    • encouters
    • sex, gender, mother's maiden name
  8. Computerized MPI Allows staff to access data in variety of ways:
    • Alphabetically
    • MR number
    • Billing number
    • Pheonetically
    • DOB
    • SS number
  9. Computerized MPI: Advantages
    • Solves space and retreival problems
    • Assist in maintaing accuracy
    • Provide other departments with immediate access of MPI
  10. 2. Number Index
    • Chronilogical list of pateint indetification number used to patients and the name of the patientassigned to each number
    • Computerized Index: computer automatically assigns a number when a new patient is registered for admission
    • Number index should be montiored for accuracy and completeness
  11. 3. Disease Index
    • A disease index lists diseases and conditions according to the classification (coding) system used by the facility
    • Becase each patient is listed with MR# and Dz. Codes, the disease index is considered patient-identifiable data.
  12. Content of a Disease Index
    Data routinely entered under the disease code:
    • Principal Dx
    • MR#
    • Sex
    • Age
    • Race/ethncity
    • Attending physician
    • Service on what the patient was hospitalized
    • End results (specifies whether death of discharged)
    • Date of Admit
    • associated diseases and procedures
  13. 4. Operation (Procedure) Index
    An operation index is a listing of surgical and prcedural code numbers arranged in numberical order by the patient's procedure codes
  14. Contents of Operation Index
    • Primary data routinely entered under the procedure performed for each patient includes:
    • MR#
    • Sex
    • Age
    • Race
    • sugeon
    • service
    • End results (Death or discharge)
    • date of admission
    • associated diseases and procedures
  15. Purpose of Drs and Op. index:
    • 1. To review previous cases of a given disease in order to provide insight into the management of a current patient's health problem
    • 2. To test theories and compare data on certain diseases/treatments
    • 3. Research
    • 4. Utilization: need for new equipment, staff, beds,  etc.
    • 5. Evaluate quality of care
    • 6. To conduct epidemiological and infection control studies
    • 7. risk management
    • Patient care data
    • Determine if treatment was necessary
    • Most expensive to maintain
  16. 5. Physician Index
    • List of cases in order of physician and number
    • Provides medical staff with a record of every patient they have treated
    • Enable users to retieve information about a particular physician
    • Confidentiallity
    • Discharge dates
  17. Uses of physician index:
    • Survey trends and changes in practice
    • Credential committe ...to identify physiciab activity profile
    • Administrative - able to identify needs for certain specialties - to note increases/decreases in individual physician's practice
  18. Index v Registry?
    • Registries contain more data
    • Registries require extensive data entry
    • Data in an index may be easily captured from a facility database
  19. Case Defining (in registries)
    A registry must define the cases to be included in the registry
  20. Case Defining?
    Case defining is the method used to identify the patients who have been seen and/or treated in the facility for the particular disease or condition of inerest to the registry.
  21. 8 Types of Hospital Registries
    • Patient Admission registy
    • Patient Discharge registry
    • Operating Room registry
    • Birth & Death registry
    • Emergency Department registry
    • Trauma registry
    • Cardiac registry
    • Cancer registry
  22. 1. Patient Admission registry
    • Admission register arranged in chronilogical order by date and time
    • Kept permently
    • Includes: MR#, Adm type, Pt's name, date of admit, physician
  23. 2. Patient Discharge registry
    • Arranged in chonilogical order by date of discharge
    • kept permently
  24. 3. Operating room registry
    • Provides statistical data for case load analysis and administrative reports
    • Keep 10 years
  25. 4. Birth & Death registry
    • Chronological listing of all births and deaths
    • Provides readily accessible information without refereing to medical record
  26. Birth Defect registy
    • Used for defects found in 1st year of life
    • defects of newborns, stillborns...
  27. 5. Emergency Department registry
    • Required by JCAHO
    • Maintained continuously
    • Includes: Naem, age, sex, date&time, means of arrival, nature f complaint, disposition, time of deprture
  28. Uses of Emergency Department registry
    • Staff planning of ED
    • Evaluate appropriateness of care
    • Evaluate quality of care
    • Research
  29. 6. Trauma registry
    • Monitor effectiveness of trauma system
    • Provides data to funding sources:
    • 1. Proprietary - developed by individual hosptial, unique to facility
    • 2. Public - develop by regional, state, federal agencies
    • 3. Commercial -develop software
  30. 7. Cardiac registry
    • Purpose: measures outcomes, monitors physican specific clinical quality
    • Uses: payers, public, planning commisions
  31. 8. Cancer registry
    • Goal: improve patient care
    • Provides a system of monitoring all types of cancer diagnosed and/or treated at an institution

    • Uses:
    • Ascertain optimal care is given, compare institution morbility or survivl rates, determine need fo public & profesional education programs, to allocate resources
  32. Components of a cancer registry
    • Components are vital t maintain cancer registry:
    • Database
    • Lifetime follow up fo patients
    • Quality control
    • Patient care evaluation
    • Use of registry data
    • Confidentiality
    • Staffing
  33. Two main objecties to cancer registries:
    • 1. Provide lifetime follow up to cancer patient
    • 2. Provide meanfingful information to the physician for patient care, evaluation, and research
    • 3. Assist in improving quality of life
  34. Data in a Cancer regsitry includes:
    • Type & site of cancer
    • Diagnostic methods
    • Treatment methods
    • Stage of time of diagnosis (staging provides information on the size and spread of the tumor)
  35. 3 types of cancer registries
    Hospital based(facility based) -operates exclusively for cancer patients treated at a particular healthcare facility

    Central registry (population based) - collects data from its designating territory, thus accumilating enough information to study trends in cancer occurences, treatments and results

    Special Purpose registry - collect data on one type of cancer(such as leukemia, lung...) looks for trends and new cases.
  36. CRAA Mandate ( Cancer registry amendament act)
    • Demographic information of each cancer case
    • Industrial or occupational hx of each cancer patient
    • Administrative info: date of dx, and source
    • Pathological date: site, stage, incidence, tx
  37. 4 files in a cancer registry
    • 1. Cancer registry master index
    • 2. Accession registry
    • 3. Case files
    • 4. Follow up
  38. 1. Cancer registry master index
    Alphebetical index of cancer patients entered into the cancer registry
  39. 2. Accession registry
    • Permanent log of all cancer patients chronological (date of dx) list of all cancer cases assigned accession number by year assigned to every patient
  40. 3. Case files/abstracts
    • Files of patinet who have recieved thier first course of treatment
    • Files by site
    • Stored by site
  41. 4. Follow up file
    • Follow up is done annually
    • A readmission constitues a follow up
  42. Record Linkage
    Process of connecting records on the same individual that have been generated at differnet times and in different places
  43. Clinical Informaiton Systems
    • functions for :
    • pateint care management
    • order entry
    • service report (nursing, pharmacy, etc..)
  44. Administrative Information Services
    • functions are:
    • Patient registration & management of finacial, HR, materials, facilities...
  45. Management Support Sustem
    • functions support:
    • Executive decision making
    • Planning & marketing
    • resource allocation...
  46. Optimum Effectiveness
    To provide high quality care and control cost at the same time, a pratitioner must have access to both clinical data and financial data
  47. Clinical Information System (1st type of HIS)
    • Patient care system: Order entry system, results reporting system, Dept. based clinical system
    • used to collect, verify and report tests results
    • Pharmacy IS: Simplify and streamline the dispensing of medications, control inventory, compare drug orders
    • Labratory sysem: used to collect, verify and report tests results
    • Pharmacy IS: Picture archiving and communication systems are used in managing digitial images
    • Radiology IS: Picture archiving and communication systems are used in managing digitial images
    • Nursing IS: Automates nursing process from assessments to evaluation
  48. EHR/EPR/CPR?
    EHR system is generally considered one that captures data from any number of computer systems in a healthcare organization and is used in at the point of care to support clinical desicion making.
  49. Advatages and barriers of EHR
    • Advantages:
    • Efficient data management
    • Accessibility to data
    • Reduction in space & time spent recording data
    • Major barriers:
    • high cost, user resistence/acceptance, security & privacy concerns, insuffienct standards and lack of organizational support.
  50. Patinet Care & Departmental Clinical systems
    Collect and maintain data captured in an encounter in an electronic
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