Chapter 7 Flashcards
(56 cards)
0
Q
What are the types of microfilm?
A
1) roll microfilm
2) jacket microfilm
3) microfiche
1
Q
What is microfilming and what should be considered when copying?
A
Microfilm is the process of producing many photograph copies
Should consider:
- The type and amount of information
- updating it
- accessing it
- budget
2
Q
General considerations for purchase of supplies?
A
- Quality of product
- design function
- costs
- reliability of manufacture
3
Q
purchase considerations
A
- Size
- tabs
- folder weight
- reinforcement on top and tabs
- Color
- pre-printing info such as logos
- pockets
- fasteners
- expandability, thickness
4
Q
Retention considerations
A
- State statutes and regulations
- facility needs
- Storage space
- Deactivation -active:3-5years
5
Q
Options of retention for medical records
A
- destruction of records
- off-site storage
- micrographics or optical imaging
6
Q
Methods of destroying paper records
A
Burning, shredding, pulping, pulverizing
7
Q
Methods for destroying microfilm
A
Recycle, pulverizing
8
Q
Destroying electronic data
A
Magnetic Degaussing
9
Q
Certificate of destruction
A
- date destructive
- method
- description of disposed records
- signed by two witnesses
10
Q
Commercial storage considerations
A
- delivery
- maintain confidentiality of records
- Insurance if fire theft flood
- billing terms
- guarantee record return
- Record tracking
11
Q
Types of health record analysis
A
1-quantitative
2-qualitative
3-statistical
12
Q
Quantitative analysis
A
A list of deficiencies for the health record:
- patient identification: on every page
- all authorization present
- all forms and reports are correct and present
13
Q
Delinquent record
A
When an incomplete record is not returned within a number of days (usually 15 to 30 days)
Fill out a deficiency slip that indicates what reports are missing
14
Q
Elements of good documentation
A
- legibility
- readability
- timeliness
- error correction
- no gaps
15
Q
Compensable event
A
And event during the hospitalization which might become a lawsuit
16
Q
Responsibilities of HIM committee
A
- timeliness and accuracy of record
- Health records clinically pertinent
- Useful and quality assessment and legal document
- determining format of medical records
- developing policies and procedures
17
Q
Outguides
A
Plastic folders in the file area to replace a record that’s been removed
18
Q
Requisition slip
A
A paper in the larger pocket of the outguide in which gives information about the record removed and where it is
Contains:
Patients name, record number, person requesting the record, date the record was signed
19
Q
Computerized record tracking system
A
Stores current and past locations of record
20
Q
Activity ratio
A
of requests / #of records on file
21
Q
Accuracy ratio
A
Records located / # records requested
22
Q
Issue in record control
A
- Transportation of records
- limit room access
- file room security
- loose reports
23
Q
Form inventory
A
Collection of all and previous revisions of forms
24
Forms justification sheet
```
Rationale should include:
-purpose of new form
-always responsible
-how form will solve problems
-how info is currently documented
-external requirements for forms:JC, CMS
-
```
25
Purposes of forms
- collect data
- instruct user
- report information
- standardize don't
- assign responsibility
- meet users needs
26
Basic designs for forms
- Meets all users needs: patient, healthcare provider..
- purpose of form: instruct, identify, report
- Technology used: barcode, touchscreen, pens
- Standard abbreviations and terminologies
- include instructions
- keep it simple: not overcrowded
27
Issues with hybrid record
- defining legal health record
- identifying components for request
- dual work process
- cost of paper and electronic record
28
EDMS
Electronic document management system
29
Workflow for hybrid record
- Record assembly: repairing torn pages, removing staples to prepare for scanning
- Record retention: 6 months after scanning
- Record retrieval: available through EDMS
- Reconciliation: resolve discrepancies
- Record processing:
1) check quality of image scanned
2) scanned within timeframe
3) Paper records are verified it belongs to patient records before scanning
30
6 functions of EDMS
1) automated forms processing
2) electronic signature
3) document capture
4) Document indexing
5) document retrieval
6) document management
31
Optical imaging system
Scanning documents into a system:
32
Names of electronic health record
1) CPR: computer-based patient record
2) EMR: electronic medical record
3) EHR: electronic health record
33
Components of EHR
- EDMS
- HIE
- Patient care charting
- CPOE-computerized provider order entry
- Data mining
34
Organization of medical staff
- Active: most active physician
- associate: new physicians
- consulting: physicians who consult on a patient
- faculty: physician who educate students
- Housestaff: resident
- courtesy: physicians who admit patients infrequently
- honorary: retired physicians who are honored
Attending physician: responsible for the care of patient during admission
Admitting physician: orders patients admission and begins care
35
Clinical organization
- medicine
- surgery
- gynecology
36
Governed medical staff
By-laws: structure of body
Rules and regulations: specific actions required of physicians
37
Medical staff committee
- credential committee: makes recommendation
- Quality improvement: evaluation of patient care
- morality and morbidity: reviews dead cases
- infection control: review hospital acquired infections
- medical record committee: timeliness of medical records and documentation
- pharmacy: review Usage of medications
38
Per diem rate basis reimbursement
Rate covered charges for room, board and services
39
Case mix index
A measure of costliness of treating hospital patients: 1.05 means patients are 5% more costly than average to treat
-most common: diagnosis related groups DRG
40
Legislative acts that fight fraud and abuse
- FCA: Federal false claims act
- HIPAA
- BBA: balanced budget act
OIG: office of Inspector General- responsible for detecting, preventing, investigating Medicare fraud and abuse
41
Delinquency rate compliance with joint commission:
-compliance:
delinquency rate not more than 50% of average monthly discharge rate AMD and no single quarterly measurement is greater than 50% AMD
-partial compliance:
Delinquency rate not more than 50% of AMD but one or more quality measurement is greater than 50%
-insufficient compliance:
Delinquency rate is greater than 50% but less then twice 200% of AMD rate
-recommendation for conditional accreditation
Is exceeds 30 days of incomplete
42
MPI
Master patient Index:
Identifies all patients admitted or treated at health care facility
43
Record identification
- alphabetical
| - Numerical
44
Numbering methods
- serial
- unit
- serial-unit
- SS#
- Family numbering
45
MPI filing system
- alphabetic
| - phonetic (soundex)
46
Numeric filing systems
- straight numeric
- terminal digit
- middle digit
47
Filing equipment
- file cabinets
- open shelf file
- movable open shelf (lateral mobile, doublebank) :
1) compressible units
2) motorized units (carousels)
48
Calculating shelves
```
1000×.5 = 500
500×.25 = 125
36×8 = 288
500+125 = 625
625÷288 = 2 .17 units ~~3 units
```
49
HIM Function
- ensure quality, security, availability of health information
- monitor quality of patient information
- Store and retrieval of patient information
- Transcriptionist
- release of information
50
EMPI
Enterprise Master patient Index:
References all patients and two or more facilities
51
Duplicate , overlay, overlap
Duplicate: a patient having duplicate medical record number
Overlay: patient assigned another patient's medical number
Overlap: more than one medical records exist for the same patient within an enterprise
52
MPI clean up process
1) deterministic algorithm: exact match of data elements
2) probabilistic algorithm: mathematical formulas that analyze MPI data
3) rules-based algorithm: assigns weights and uses them to compare record
53
Duty of care
Time of creation to time of destruction
54
Addendums
A type of correction.
| Signed report that provides additional information after a previous entry
55
Access control
- authentication: verify identity (ID and password, access card)
- authorization: right given to use a resource
- nonrepudiation: unable to deny action
