Chapter 3 - Health Information Functions, Purpose, and Users

Question 1

difference between data, information, and knowledge

Answer 1

Data are raw facts and figures (e.g. Hospital A discharged 560 patients last month). Information is data that have been turned into something meaningful (e.g. Hospital A discharged 560 patients last month, which was up 10 percent from the prior month and 20 percent from this time last year). Knowledge is the information, understanding, and experience that give individuals the power to make informed decisions. (e.g. investigation identified that the increase in patients was primarily due to an increase in obstetrics patients. This increase in obstetrics patients is why the healthcare organization decided to investigate ways to improve its obstetric services.)

Question 2

primary purpose of the health record

Answer 2

the primary reason a health record exists is for the sake of providing patient care and the billing for that patient care

Question 3

secondary purpose of the health record

Answer 3

the secondary reason a health record exists is for healthcare purposes not directly related to patient care (such as research or for the education of new healthcare professionals)

Question 4

interoperability

Answer 4

the ability of computer systems, software, or groups of people to exchange and make use of information

Question 5

aggregate data

Answer 5

data that have been extracted from individual health records and combined to form deidentified information about groups of patients that can be compared and analyzed

Question 6

patient care providers

Answer 6

physicians, nurses, and other allied health professionals who rely on information from the health record to make decisions about the care provided to the patient

Question 7

coding and billing staff

Answer 7

(Documentation in the health record is the basis for reimbursement, or payment, for the care provided.) The coding staff at the healthcare organization must read the entire health record and assign the appropriate diagnoses and procedure codes for treatment received during the encounter. The billing staff obtains the codes from the coders and submits the bill to the insurance company.

Question 8

turnaround time

Answer 8

the time between receipt of request for information and when the information is sent to the requester

Question 9

abstracting

Answer 9

either: (1) the process of extracting information from a document to create a brief summary of a patient’s illness, treatment, and outcome; or (2) the process of extracting elements of data from a source document or database and entering them into an automated system

Question 10

document management system (DMS)

Answer 10

a system that scans the paper record and stores it digitally; the user has the benefits of immediate access but unfortunately the user is not able to manipulate the data as the document is stored as a picture, not data.

Question 11

master patient index (MPI)

Answer 11

the permanent record of all patients treated at a healthcare organization

Question 12

demographic data

Answer 12

statistical data relating to the population and particular groups within it (e.g. basic information such as name, address, and date of birth of patients)

Question 13

enterprise master ­patient index (EMPI)

Answer 13

a master patient index shared among multiple healthcare organizations

Question 14

duplicate health record

Answer 14

something that results when the patient has two or more health records issued; in this situation, the patient’s health information becomes fragmented with some information under the first number and the remainder under the second number. When this happens, excessive testing and medical errors may result

Question 15

overlay

Answer 15

(in the context of health records) something that happens when a patient is erroneously assigned to another person’s health record; when this happens, patients get mixed up and medical errors can result; one of the more common reasons for this is an error in selecting the correct patient by the hospital staff.

Question 16

overlap

Answer 16

something that results when a patient has more than one health record number at different locations within an enterprise or healthcare organization. This frequently becomes an issue when healthcare organizations merge or create an EMPI.

Question 17

deterministic algorithm

Answer 17

an algorithm that requires exact matches in data elements such as the patient name, date of birth, and social security number

Question 18

probabilistic algorithm

Answer 18

an algorithm that uses mathematical probabilities to determine the possibility that two patients are the same

Question 19

rules-based algorithm

Answer 19

an algorithm that assigns weights to specific data elements and uses those weights to compare one record to another

Question 20

alphabetic filing system

Answer 20

a filing system where health records are filed in alphabetic order; this system works well with a small volume of health records such as in a physician practice. Employees are comfortable with it and the filing system is easy to create and use. A disadvantage is that there is no unique identifier as patients can have the same name. Another problem is the alphabetic filing system does not expand evenly. Statistically almost half of the files fall under the letters B, C, H, M, S, and W.

Question 21

numeric filing system

Answer 21

a filing system where the health records are filed by the health record number. The MPI is consulted to identify the health record number and then the number is used to locate the health record. This may seem like more work than the alphabetic system but there are many more advantages to using it

Question 22

straight numeric filing system

Answer 22

a numeric filing system that files the records in straight numeric order based on the health record number; this filing system is easy to teach to new employees; however, the most ­active area in the files is the higher numbers, which are the most current files, ­making it difficult to manage.

Question 23

terminal-digit filing system

Answer 23

typically considered the most efficient of the numeric filing systems in part because it distributes health records evenly throughout the filing units. It is also effective for healthcare facilities with a heavy record volume.

Question 24

health record number for a terminal-digit filing system

Answer 24

example: 12-34-56; 12 is tertiary digits, 34 is the middle digits, 56 is the terminal digits; the record is filed back to front, starting with the terminal digits, moving on to the middle digits, and ending with the tertiary digits

Question 25

alphanumeric filing system

Answer 25

a filing system where both alphabetic and numeric characters are used to sort health records

Question 26

centralized unit filing system

Answer 26

a filing system where any patient encounters are filed together in a single location

Question 27

microfilm

Answer 27

a ­photographic process that reduces an original paper document into a small static image on film

Question 28

outguide

Answer 28

a card placed in a file to indicate the location of material that has been temporarily removed

Question 29

requisition

Answer 29

the act of either (a) formally requiring or requesting something or (b) calling upon someone to perform an action

Question 30

record reconciliation

Answer 30

the process of making sure that all records from patient encounters have been received and combined into a single health record

Question 31

record assembly

Answer 31

the process of ensuring each page in the health record is organized in a standardized format, which varies by healthcare organization. During the assembly process each page should be reviewed to ensure all thepages belong to the same patient and same encounter.

Question 32

record analysis

Answer 32

a review of the health record that is performed by the HIM department to determine the completeness of a health record. Two types of analysis should be performed—qualitative and quantitative.

Question 33

qualitative analysis

Answer 33

the act of monitoring the quality of medical documentation

Question 34

quantitative analysis

Answer 34

a review of the health record to determine if there are any missing ­reports, forms, or signatures; this can be performed through either concurrent review or retrospective review

Question 35

concurrent review

Answer 35

quantitative analysis that is performed while the patient is still receiving care at the healthcare organization

Question 36

retrospective review

Answer 36

quantitative analysis that is performed after the patient is discharged from a healthcare organization

Question 37

deficiency slip

Answer 37

a document that is created during quantitative analysis; it identifies the health record and what needs to be done to fix it

Question 38

delinquent record

Answer 38

a health record that remains incomplete (something that needs to be in there is not in there) for a specified number of days, usually more than 15 or 30.

Question 39

addendum

Answer 39

something added to a previously existing written document

Question 40

amendment

Answer 40

in the context of healthcare records, a clarification made to healthcare documentation after the original document has been signed; it should be dated, timed, and signed

Question 41

standards

Answer 41

fixed rules that must be followed

Question 42

guideline

Answer 42

general direction about the design of something

Question 43

audit trail

Answer 43

a chronological set of computerized records that provides evidence of information system activity (log-ins and log-outs, file accesses) used to determine security violations

Question 44

indexing

Answer 44

the linking of patient name, health record number, document type, and other identifying information to a scanned document

Question 45

version control

Answer 45

something that identifies which version(s) of the documents is available to the user. All versions must be maintained but access to all except the current version should be controlled so that there is no confusion about which version is correct.

Question 46

version

Answer 46

a particular form of something differing in certain respects from an earlier or later form; versions are created when addendums, corrections, or amendments are made to original documents

Question 47

free-text data

Answer 47

the unstructured narrative data that are the result of a person typing data into an information system (in other words, freewriting done in a text box)

Question 48

natural language processing (NLP)

Answer 48

a technology that converts human language into data that can be translated then manipulated by computer systems

Question 49

data mining

Answer 49

the process of extracting and analyzing large volumes of data from a database for the purpose of identifying hidden and sometimes subtle relationships or patterns and using those relationships to predict behaviors

Question 50

input mask

Answer 50

a string of characters that indicates the format of valid input values (e.g. 2065551212 becomes 206-555-1212 when it’s in the phone number field)

Question 51

serial numbering system

Answer 51

an inefficient system where a patient is issued a unique numeric identifier for every encounter at the healthcare organization. If a patient is admitted to the healthcare organization five times, he or she will have five different health record numbers. The documentation for each of the encounters is filed in the health record for that encounter so the information is filed separately, and all health records must be retrieved to view the complete health information

Question 52

unit numbering system

Answer 52

a system commonly used in large healthcare organizations because it does not have many of the inefficiencies of the serial numbering system. The patient is issued a health record number at the first encounter and that number is used for all subsequent encounters. This system consolidates all the information on the patient in one location and is therefore more efficient than the serial numbering system.

Question 53

serial-unit numbering system

Answer 53

a combination of the serial and unit numbering systems. The patient is issued a new health record number with each encounter, but all the documentation is moved from the last number to the new number. It would have many of the same advantages and disadvantages as the serial and unit numbering systems.

Question 54

patient account number

Answer 54

a number that is assigned to the patient in order to identify a specific account or date(s) of service

Question 55

statistics

Answer 55

a branch of mathematics concerned with the collecting, organizing, summarizing, and analyzing of numerical data

Question 56

registry

Answer 56

a collection of patient care information related to a specific disease, condition, or procedure that makes health record information available for analysis and comparison

Question 57

patient registration department

Answer 57

a health information department that creates the health record and puts in basic patient information such as name, age, and date of birth

Question 58

billing department

Answer 58

also called patient financial services; a health information department that uses the codes assigned and data abstracted by the coders as part of the billing process (made up of medical coders and medical billers)

Question 59

patient care department

Answer 59

the healthcare professionals responsible for providing direct patient care

Question 60

information systems department

Answer 60

the department that maintains the computer systems needed to house all of the medical information

Question 61

quality management department

Answer 61

the department that performs qualitative analysis through committee meetings, audits, and outcome monitoring

Question 62

medical transcription

Answer 62

the manual processing of voice reports dictated by physicians and other healthcare professionals into text format

Question 63

encoder

Answer 63

a program used to assign the diagnosis and procedure codes

Question 64

grouper

Answer 64

a program that uses medical codes already assigned to determine the diagnostic-­related group or another grouping category

Question 65

computer-assisted coding

Answer 65

a program that uses EHR data to directly assign medical codes; in this situation, the medical coder reviews the codes for accuracy rather than directly assigning them

Question 66

DRG

Answer 66

acronym for diagnosis-related group; a system to classify hospital cases into a specific group, selected from one of many types of groups; it is used by Medicare and some insurance companies to determine payment

Question 67

clinical decision support (CDS)

Answer 67

a medical technology that assists physicians and other users when making decisions regarding medications, diagnoses, and such based on the information entered into the EHR (electronic health record). The EHR contains alerts and reminders to notify the user of medication allergies, tests that should be performed, immunizations due, and so forth. Benefits include reduction in administrative costs and improvement in quality of care.