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what dr records and is put into written word-
transcription
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thought/comprehended-
contextual
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HIM dept's typically manages the following support services-
- record processing
- monitoring of record completion
- transcription
- release of patient info
- clinical coding
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HIM dept may manage the following functions:
- research & statistics
- cancer and/or trama registries
- birth certificate completion
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what works & doesn't; what needs to be changed-
work flow analysis
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EDMS-
electronic document management systems
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part of EHR; documents to help manage-
EDMS
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MPI-
master patient index
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primary guide to locating pertinent demographic data about the patient & his/her health record #; permanent record of every patient ever seen in the healthcare entity-
MPI
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Basic info usually included in the MPI-
- patients last, first & middle names
- patients health record #
- patients date of birth
- patients gender
- dates of encounter (admission & discharge dates are usually maintained for inpatients)
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patients registration system, also known as the registration, admission, discharge, transfer system-
R-ADT
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assignment of a new patient medical record # to an individual that has an existing medical record #-
duplicate medical record #
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a patient is assigned another patients medical record #-
overlay
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when more than 1 medical record # exists for the same person within an enterprise at different facilities or in different databases-
overlap
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2 different MPI's & makes a bigger/huge system-
EMPI
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HIE-
health information exchange
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frequently used to describe both the sharing of health infomation electronically among 2 or more entities & also an organization that provides service to accomplish this info exchange-
HIE
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key date element in the MPI-
health record #
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patient receives a unique numerical identifier for each encounter or admission to a healthcare facility/#'s are issued in a series-
serial numbering system
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most commonly used; the patient receives a unique health record # at time of the first encounter and the same # is used every visit-
unit numbering system
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numbers are assigned in a serial manner, but during each new patient encounter, the previous health records are brought forward & filed under the last assigned health record #-
serial-unit numbering system
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patient's last name is used as the 1st source of identification & his/her first name & middle initial provide further id-
alphabetic identification and filing system
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the method most commonly used as the unique identifier in the EHR environment-
unit numbering
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records are filed by health record #; is an indirect filing system; an index or authority file needs to be consulted before the user can identify a record assoc. w/a specific patient ie: master patient index-
numeric filing system
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records are assigned consecutively in ascending (smaller to larger) numberic order; the # assigned to each file is the health record #
straight numeric filing system
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considered most efficient; the last digit or group of last digits is the primary unit used for filing, followed by the middle unit & the last unit of #'s; (file#, shelf, row)-
terminal digit filing system
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the primary unit is the middle unit, the secondary unit is the 1st unit to the left, followed by the last digits (shelf, row, file#)-
middle digit filing system
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uses a combination of alpha letters & #'s for identification purposes; the 1st 2 letters of the patient's last name are followed by a unique numeric identifier; this system is appriopriate for small organizations-
alphanumeric filing system
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individual patient encounters are filed by the same unique identifier & in the same location; the unique identifier can be alphabetic, alpha-numeric or numeric-
centralized unit filing system
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converts paper documents to archive-stored images by taking a picture of the original document & storing it as a very small negative-
milcrofilming process
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negative of health records; have mulitple #'s (serial # unit) on multiple rolls of films-
roll microfilm
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microfilm cut & put into folders; put together for 1 person; alphabetic, straight, numerical, terminal digit used-
jacket microfilm
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everything is departmentalized; labs, radiology, etc are together, copied & put on microfilm; never remove3d from dept unless record is old-
microfiche
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request from a clinical or other area in the organization to charge out a specific health record; may be in paper or electronic form; the form usually includes patient's name, health record #, date of request, date & time needed, name of requestor & location for delivery-
requistion
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incomplete record that is not rectified within a specific # of days as indicated in the medical staff rules & regulations-
deliquent record
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review for deficiencies by the HIM dept is called-
quantitative analysis
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review occurs concurrently with the patient's stay in the hospital-
concurrent review
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process of extracting data from the health record & entering them into a computer database-
abstracting
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indexes, diagnoses and operative codes that are used as guides or pointers to the health records of patients who have had a specific disease or operation; are essential for locating health records to conduct quality improvement & research studies, as well as monitoring quality of care-
disease and operation index
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index that is a guide to identifying medical cases associated with a specific physician-
physician index
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a non-profit organization that offers an accreditation program for hospitals and other healthcare orgainzations based on pre-established accreditation standards=
Joint commission
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Other entities beside TJC that have established documentation standards-
- Medicare conditions of participation
- National Committee for Quality Assurance (NCQA)
- American Accreditation Health Care Commission/Utilization Review Accreditation Comm
- American osteopathic Association (AOA)
- Commission on Acdcreditation of Rehalbilitation Facilities (CARF)
- Health Accreditation Program of the National League of Nursing
- College of American Pathologists (CAP)
- American Association of Blood Banks (AABB)
- American College of Surgeons (ACS)
- Accreditation Association for Ambulatory Health Care (AAAHC)
- American NMedical Accreditation Program (AMAP)
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Healthcare organizations accredited by TJC are also deemed to be in compliance with the Medicare Conditions of Participation-
deemed status
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a plan that converts the organizations goals and objectives into targets for revenue and spending; its a planning tool as well as an evaluation tool-
budget
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a predication of how much money an organization's activities will generate during a certain period-
revenue budget
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a predication of how much expense an organization is going to generate; includes such things as employee salaries and supplies-
expense budget
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a projection or plan of what the organization intends to spend on long-lived assets such as a piece of equipment-
capital budget
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the anticpated flow of cash into and out of the organization (donations, petty cash)-
cash budget
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the process in which digital text stored on computer can be read by software and automatically coded-
Natural Language Processing (NLP)
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would have enterprise or facility wide responsibiltiy for HIM; includes working w/the chief information executive & system users to advance systems, methods, & application support & to imporve data quality, access, privacy, security & usability-
health information manager/Vision 2016
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would perform data management functions in a variety of application areas, including clinical coding, outcomes management, specialty registries and research databases-
clincial data specialist/Vision 2016
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would perform new service roles that help consumers manage their personal health info, including personal health history management, ROI, managed care services & information resources-
patient information coordinator/Vision 2016
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would perform functions involving formalized continuous quality improvement for data integrity throughout the enterprise, beginninbg w/data dictionary & policy development & including quality monitoring & audits-
data quality manager/Vision 2016
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would be responsible for the next generation of records & data management using media such as CPR, the data repository & electronic warehousing for meeting current & future care needs across the continuum, providing access to the needed information & ensuring long-term integrity and access-
date resource administrator/Vision 2016
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would support senior management w/info for decision making & strategy development using a variety of analytical tools & databases; the position would work w/product & policy organizations on high-level analysis projects such as clinical trials & outcomes research-
research and support analysis/Vision 2016
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manage the security of all electronically maintained info, including the promulgation of security requirements, policies and privilege systems and performance audits-
security officer
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CAC-
computer assisted coding
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