Chapter 2: Purpose and Function of the Health Record Flashcards
What is the Health Record?
A paper or computer-based tool for collecting and storing information about the healthcare services provided to a patient in a single healthcare facility.
What is Data?
The dates, numbers, images, symbols, letters, and words that represent basic facts and observations about people, processes, measurements, and conditions.
What is Information?
Factual data that have been collected, combined, analyzed, interpreted, and/or converted into a form that can be used for a specific purpose.
What is the Electronic Health Record?
An electronic record of health-related information on an individual that conforms to nationally recognized interoperability standards and that can be created, managed, and consulted by authorized clinicians and staff across more than one healthcare organization.
What is the Personal Health Record?
An electronic record of health-related information on an individual that conforms to nationally recognized interoperability standards and that can be drawn from multiple sources while being managed and controlled by the individual.
What are the primary purposes of the health record?
Patient care delivery, patient care management, patient care support services, financial and administrative, patient self-management.
What are secondary purposes of the health record?
Education, regulation, research, public health and homeland security, policy making and support, industry.
What are Accreditation Organizations?
A professional organization that establishes the standards against which healthcare organizations are measured and conducts periodic assessments of the performance of individual healthcare organizations.
What is a Third-Party Payer?
An insurance company or healthcare program that reimburses healthcare providers and/or patients for the delivery of medical services.
Who are the primary users of the health record?
Patient care providers
What are Quality Improvement Organizations?
An organization that performs medical peer review of Medicare and Medicaid claims, including review of validity of hospital diagnosis and procedure coding information, completeness, adequacy, and quality of care; and appropriateness of prospective payments for outlier cases and nonemergent use of the emergency room.
What are Utilization Management Organizations?
An organization that reviews the appropriateness of the care setting and resources used to treat a patient.
What is Data Quality Management?
A managerial process that ensures the integrity of an organization’s data during data collection, application, warehousing, and analysis.
What are the four domains of Data Quality Management?
Data applications, data collection, data warehousing, data analysis.
What are the ten quality characteristics?
Accuracy, accessibility, comprehensiveness, consistency, currency, definition, granularity, precision, relevancy, timeliness.
