Chapter 3 - Health Information Functions, Purpose, and Users Flashcards
difference between data, information, and knowledge
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.)
primary purpose of the health record
the primary reason a health record exists is for the sake of providing patient care and the billing for that patient care
secondary purpose of the health record
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)
interoperability
the ability of computer systems, software, or groups of people to exchange and make use of information
aggregate data
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
patient care providers
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
coding and billing staff
(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.
turnaround time
the time between receipt of request for information and when the information is sent to the requester
abstracting
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
document management system (DMS)
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.
master patient index (MPI)
the permanent record of all patients treated at a healthcare organization
demographic data
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)
enterprise master patient index (EMPI)
a master patient index shared among multiple healthcare organizations
duplicate health record
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
overlay
(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.
overlap
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.
deterministic algorithm
an algorithm that requires exact matches in data elements such as the patient name, date of birth, and social security number
probabilistic algorithm
an algorithm that uses mathematical probabilities to determine the possibility that two patients are the same
rules-based algorithm
an algorithm that assigns weights to specific data elements and uses those weights to compare one record to another
alphabetic filing system
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.
numeric filing system
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
straight numeric filing system
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.
terminal-digit filing system
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.
health record number for a terminal-digit filing system
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
alphanumeric filing system
a filing system where both alphabetic and numeric characters are used to sort health records
centralized unit filing system
a filing system where any patient encounters are filed together in a single location
microfilm
a photographic process that reduces an original paper document into a small static image on film
outguide
a card placed in a file to indicate the location of material that has been temporarily removed
requisition
the act of either (a) formally requiring or requesting something or (b) calling upon someone to perform an action
record reconciliation
the process of making sure that all records from patient encounters have been received and combined into a single health record
record assembly
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.
record analysis
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.
qualitative analysis
the act of monitoring the quality of medical documentation
quantitative analysis
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
concurrent review
quantitative analysis that is performed while the patient is still receiving care at the healthcare organization
retrospective review
quantitative analysis that is performed after the patient is discharged from a healthcare organization
deficiency slip
a document that is created during quantitative analysis; it identifies the health record and what needs to be done to fix it
delinquent record
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.
addendum
something added to a previously existing written document
amendment
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
standards
fixed rules that must be followed
guideline
general direction about the design of something
audit trail
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
indexing
the linking of patient name, health record number, document type, and other identifying information to a scanned document
version control
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.
version
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
free-text data
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)
natural language processing (NLP)
a technology that converts human language into data that can be translated then manipulated by computer systems
data mining
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
input mask
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)
serial numbering system
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
unit numbering system
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.
serial-unit numbering system
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.
patient account number
a number that is assigned to the patient in order to identify a specific account or date(s) of service
statistics
a branch of mathematics concerned with the collecting, organizing, summarizing, and analyzing of numerical data
registry
a collection of patient care information related to a specific disease, condition, or procedure that makes health record information available for analysis and comparison
patient registration department
a health information department that creates the health record and puts in basic patient information such as name, age, and date of birth
billing department
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)
patient care department
the healthcare professionals responsible for providing direct patient care
information systems department
the department that maintains the computer systems needed to house all of the medical information
quality management department
the department that performs qualitative analysis through committee meetings, audits, and outcome monitoring
medical transcription
the manual processing of voice reports dictated by physicians and other healthcare professionals into text format
encoder
a program used to assign the diagnosis and procedure codes
grouper
a program that uses medical codes already assigned to determine the diagnostic-related group or another grouping category
computer-assisted coding
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
DRG
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
clinical decision support (CDS)
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.
