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Dynamics of Health Care > chapter 17 > Flashcards

chapter 17 Flashcards

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1
Q

What do healthcare providers do to patient records (5)

A 
enter it into the computer
edit it 
file it 
search in it 
retrieve it
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2
Q

What must healthcare professionals adhere to

A

HIPPA

Health insurance portability and accountability act

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3
Q

name some documents in a patients record

A 
insurance form
patient health record
physician order
notes 
test reports
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4
Q

What is the most used medical record system

A

the electronic medical record system

- computerized documentation has transformed record keeping

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5
Q

What are two main purposes of organized medical documentation

What are the 4 less obvious purposes?

A
  • communicating with other HC professionals
  • describing patient’s current medical condition and history
  • reimbursement requests
  • maintaining a legal record
  • education
    supporting research
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6
Q

Describe communication and medical documentation

A

a patient has several healthcare providers, which do not interact. the medical documentation allows each healthcare professional to have access to accurate records

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7
Q

What does a patient’s health and well being depend on

A

the accuracy of his/her medical records

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8
Q

What are the four assessment data

A 
vital signs 
- temperature 
- pulse
- blood pressure
- respiration rate 
circumstances surrounding visit
symptoms 
medical history
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9
Q

What helps determine the right diagnoses and treatment plans

A

current and past assessment information

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10
Q

What is quality assurance

A

to provide evidence of the quality of care a patient received and the competence of the professionals who provided the care

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11
Q

How is quality assurance checked

A

a committee might select random medical records to review and compare to standards of care

OR

Accrediting agencies may review medical documents to determine whether an institution is meeting its standards

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12
Q

What happens if quality assurance defeciences are found

A

in service training is provided

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13
Q

Link patient records to reimbursment

A

Patient records verify the care a patient received when a provider seeks reimbursement from the insurance or government plan/policy.

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14
Q

What type of documents are used in reimbursement (5)

A
  • reason for patients visit
  • type of care made
  • diagnosis made
  • test ordered
  • treatments provided

overall the plan administrator’s decision about how much the provider will be paid is dependent on this

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15
Q

What do medical record systems assign to the services a patient receives

A

a code

- the code is submitted to the insurance company or government plan for review

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16
Q

What two things do insurance companies or government plans review

A

billing codes

patient records

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17
Q

What three standards should healthcare professionals adhere to

A

legal
moral
ethical

= if not this results in a breach of contract
= the provider is subject to fines or lawsuits

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18
Q

When are patient records useful in court

A

if a healthcare professional is charged with improper care or malpractice

when a patient makes accident or injury claims

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19
Q

How are patient records used in education

A

providers use patient records as educational tools to train new people in the field

can be used during clinical portions of health education programs

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20
Q

Why do researchers use patient medical records

A

learn how to best recognize or treat health problems by examining similar cases

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21
Q

What three uses come form data gathered from patient records

A
  • significant similarities in disease presentation
  • contributing factors
  • effectiveness of therapies
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22
Q

What advantages does computerized documentation have over traditional paper charts (6)

A
  1. information is easy to store and retrieve
  2. unlimited file space
  3. easy to backup for extra security
  4. information is easily added and attached
  5. charting is easier to read
  6. typing is faster than writing
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23
Q

What does computerized documentation allow that handwritten doesnt

A

multiple users to access the same portion of a record simultaneously
- ease of access

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24
Q

why do hc facilities use computers (3)

A

order supplies and services
store billing and financial data
maintain health care information

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25
what has the increased use of computerized medical information brought about the need for
policies and procedures ensuring privacy and confidentiality of patient information
26
what should patient privacy policies state (3)
which types of patient information can be retrieved who can retrieve information why can someone retrieve information
27
What are recommendations by AHIMA for safe computer recordkeeping (9)
- never give personal password or signature to others - do not leave computer terminal unattended after logging on - follow correct protocol for correcting errors (e.g. mistaken entry or mistaken entry-wrong chart) - allow authorized personnel to create, change, delete records - ensure that records are backed up - do not leave patient information on display - keep a running log of electronic copies made of computerized files - never use email to send protected health information - follow agency confidentiality procedures for documenting sensitive material
28
What is a patients medical record
compilation of health-related information. permanent recordd etailing medical history, test results, and interactions with healthcare professionals
29
when is an admission sheet used
used to gather information from the patient before the visit with the provider. - may be mailed to new patients before scheduled visit
30
What two types of data does admission information include
demographic data | insurance information
31
When is admission information updated? why
once a year | - a lot of patient information included address, phone number, insurance can change in one year
32
What do most healthcare facilities require with admission forms
copy of patients health insurance forms
33
What type of data does a graphic or flow sheet record
vital signs - respiration rate - blood pressure - pulse - temperature weight height
34
What is a graphic or flow sheet
used to record and monitor patient variables over time in a GRID LIKE FORM
35
what does a graphic sheet contain
history of patient vital signs and the date they were taken | - fluctuation in measurements can affect a person's health
36
what is the physician's order section
section of the patient record documents any orders for patient care including - medications - treatments - tests - follow up care
37
What does the physician's orders section include (4)
information relating to the order - medication dosage - treatment specifics - type of testing to be conducted - dates for follow up care
38
what is the advantage of 'physician's orders' being electronic
providers can send information to health care professionals including pharmacists, specialists, lab technicians eliminates human error caused by lost paperwork and misread orders
39
what are progress notes
record each contact a provider has with the patient, whether in person, phone, mail, email
40
what information may be in progress notes
provider summarizes findings that resulted from the contact - effects of treatment - change in condition - other provider information provides snapshot of treatment, progress, and issues provider must record date and time of entry + name
41
Why should progress notes be electronic
progress notes do not follow a standard format, so handwritten ones may be difficult to read = leaves little room for human error and misunderstandings
42
What is in a medical history and examination sheet
``` patient history family history social history results of physical examination current medical condition ```
43
what does the patient history section do
address patient's current and prior health status and helps provider plan appropriate care for present illness
44
what is in the patient history section (7)
``` allergies immunization childhood disease current and past medication previous illness surgeries hospitalizations ```
45
why is the family history section improtaant
some diseases may be hereditary some diseases may be familial cause of death of prev. family members
46
what does social history information cover (4)
patient lifestyle - martial status - occupation - education - hobbies patient diet use of alcohol and tobacco sexual history
47
why is the social history information important
provide guide for patient education
48
what is the reports section of patient's record
reports or findings from tests/lab work | tests in provider's office and other
49
what is the correspondences and miscellaneous documentation section
correspondence - correspondence btwn. provider and patient - letter or memos a provider send to to others concerning patient - correspondence regarding patient recieved from other provider miscellaneous - HIPPA privacy notice - end of life decisions - organ dontation, living will, durable power of attorney
50
what are the 5 char. of good med. documentation
``` accuracy completeness conciseness legibility organization ```
51
what 3 things should be ensured in accuracy
correct spelling, med term, abbreviation, acrononym all entries include facts errors are marked good
52
how should errors be marked in paper and electronic documentation
crossed with single line and identified with word error in paper add note called mistaken entry in electronic - initials - date - time
53
what is a key rule of accuracy in medical documentation
DO NOT delete or erase anything
54
what is the first rule of accuracy
make sure you are working on the correct patient
55
describe conciseness in medical records
brief entries with relevant information partial sentences and phrases use term patient use acceptable abbreviations and acrnonyms
56
what is a rule of thumb in conciseness of med. documentation
when in doubt | spell in out
57
describe completeness in med. documentation
include ALL relevant information
58
describe legibility in med. documentation
take time to ensure that writing is neat and legible
59
describe legbility in electronic med. documentation
when using stylus to write, computer will let you know if writing is legible or illegible
60
what are the two organizatino methods in med. documentation
problem-oriented medical record (POMR) | source-oriented medical record (SOMR)
61
what are the four parts of the POMR system
1. problem list - contains every problem that patient has requiring med. treatment 2. database - items (med. history, review of systems, lab reports) about patient 3. treatment plan - tests and treatments each prob. needs 4. progress notes - numbered and grouped together
62
describe the POMR problem list
medical problem listed on first page and assigned number all documentation about that problem is assigned that number when problem no longer exists, the information is recorded in the progress notes and an X is marked next to the problem
63
describe the source oriented medical record
group information by type not problem | e.g. all radiology reports are in one group
64
what is the rule followed w. medical organization
most recent information appears first in the section (on top of existing documentation) - creating reverse order of information all entries have date, time, and initials
65
what are the 3 types of progress notes
narrative SOAP charting by exception
66
describe paper used for progress notes
lined paper with two columns for progress notes - date and time of the contract in narrow left column - notes about contact in right column some offices use plain or lined paper without column
67
What must be present regardless of paper used in progress notes
date time signature credentials of individual
68
describe narrative format
``` oldest and least structured paragraph indicating - contact w. patient - what was done for patient - outcomes ``` time consuming and difficult to read
69
what type of organization are SOAP notes used for
problem oriented
70
what does soap stand for
subjective data objective data assessment plan
71
what is subjective data
includes statements from patient describing condition - symptoms w. patients exact words - not measurable
72
what is objective data
information from the health care professionals observations - measure - see - feel - smell - test results - vital signs
73
what is assessment of SOAP notes
patient diagnosis based on analysis of subjective and objective data either final diagnosis or possible disorders to be ruled out
74
what is the plan of SOAP notes
what should be done about the problem - diagnostic tests - treatments - follow ups
75
what is charting by exception
abbreviated documentation method that uses SIGNIFICANT or ABNORMAL Findings strictly problem-oriented
76
which type of progress notes are most common with electronic format
charting by exception
77
what are 8 advantages of charting by exception
decreased charting time = more free time for direct patient care emphasis on significant data easy retrieval of significant data timely bedside charting standardized assessment interdisciplinary communication better tracking of important patient responses lower costs
78
what do times do in medical documentation
specify when an action was taken or when it should begin
79
what type of time is used in medicine
military time- 24 hour cycle that counts the hours of the day from 0000 to 2359
80
why is military time used
to prevent confusion with am and pm times
81
describe content in organization of medical doc.
enter information accurate, concise, current and factual record patient findings not interpretation of findings avoid words w. multiple meanings (good, normal) avoid generalizations use chronological order chart precautions and prevention methods document all medical visits and consultations document concerns avoid stereotypes or derogatory terms
82
why is documentation important
gives legal protection to you, other caregivers, health agency or institution, and patient
83
describe timing in organization of medical doc.
``` record information in timely manner indicate date and time of each entry use military time documentation when the action happened never document BEFORE action happens ```
84
describe formatting in organization of medical doc
make sure you have correct patient record document in form noted by health institution print legibility in dark ink date and time each entry do not skip lines
85
describe accountability in organization of medical doc.
title and sign each entry draw a single line through errors identify each page with patients name and identification number
86
describe confidentiality in medical doc
keep information private | do not use actual patient names and identifiers for students

Dynamics of Health Care (21 decks)

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