Chpt 8 test.txt

what dr records and is put into written word-

written-

thought/comprehended-

HIM dept's typically manages the following support services-

HIM dept may manage the following functions:

what works & doesn't; what needs to be changed-

EDMS-

part of EHR; documents to help manage-

MPI-

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-

Basic info usually included in the MPI-

patients registration system, also known as the registration, admission, discharge, transfer system-

assignment of a new patient medical record # to an individual that has an existing medical record #-

a patient is assigned another patients medical record #-

when more than 1 medical record # exists for the same person within an enterprise at different facilities or in different databases-

2 different MPI's & makes a bigger/huge system-

HIE-

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-

key date element in the MPI-

patient receives a unique numerical identifier for each encounter or admission to a healthcare facility/#'s are issued in a series-

most commonly used; the patient receives a unique health record # at time of the first encounter and the same # is used every visit-

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 #-

patient's last name is used as the 1st source of identification & his/her first name & middle initial provide further id-

the method most commonly used as the unique identifier in the EHR environment-

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-

records are assigned consecutively in ascending (smaller to larger) numberic order; the # assigned to each file is the health record #

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)-

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#)-

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-

individual patient encounters are filed by the same unique identifier & in the same location; the unique identifier can be alphabetic, alpha-numeric or numeric-

converts paper documents to archive-stored images by taking a picture of the original document & storing it as a very small negative-

negative of health records; have mulitple #'s (serial # unit) on multiple rolls of films-

microfilm cut & put into folders; put together for 1 person; alphabetic, straight, numerical, terminal digit used-

everything is departmentalized; labs, radiology, etc are together, copied & put on microfilm; never remove3d from dept unless record is old-

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-

incomplete record that is not rectified within a specific # of days as indicated in the medical staff rules & regulations-

review for deficiencies by the HIM dept is called-

review occurs concurrently with the patient's stay in the hospital-

process of extracting data from the health record & entering them into a computer database-

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-

index that is a guide to identifying medical cases associated with a specific physician-

a non-profit organization that offers an accreditation program for hospitals and other healthcare orgainzations based on pre-established accreditation standards=

Other entities beside TJC that have established documentation standards-

Healthcare organizations accredited by TJC are also deemed to be in compliance with the Medicare Conditions of Participation-

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-

a predication of how much money an organization's activities will generate during a certain period-

a predication of how much expense an organization is going to generate; includes such things as employee salaries and supplies-

a projection or plan of what the organization intends to spend on long-lived assets such as a piece of equipment-

the anticpated flow of cash into and out of the organization (donations, petty cash)-

the process in which digital text stored on computer can be read by software and automatically coded-

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-

would perform data management functions in a variety of application areas, including clinical coding, outcomes management, specialty registries and research databases-

would perform new service roles that help consumers manage their personal health info, including personal health history management, ROI, managed care services & information resources-

would perform functions involving formalized continuous quality improvement for data integrity throughout the enterprise, beginninbg w/data dictionary & policy development & including quality monitoring & audits-

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-

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-

manage the security of all electronically maintained info, including the promulgation of security requirements, policies and privilege systems and performance audits-

CAC-