Chapter 4 Flashcards
centralized registration
type of hospital registration in which all patients presenting for nay type of care are registered through one central area, regardless of the type of care being sought
decentralized registration
type of hospital registration in which there are multiple points of patient access, depending on the type of care being sought-inpatient admission, emergency department, out patient diagnostics, ambulatory surgery, and so on
administrative data
nonmedical data, such as a patients identifiers, insurance-related data, authorizations, and business correspondence
demographic data
administrative data that identify the patient- name, date of birth, address, and gender
clinical data
data found in a health record that are of a medical nature-past medical or surgical history, vital signs, test results, physician progress notes, nurses’ notes and so on
master patient (person) index (MPI)
a permanent listing of all patients who have been admitted to or received care in a healthcare facility’ it is the key to locating patient records in a facility and is maintained permanently
medical record number
a unique numeric identifier for each patient seen in a health facility’ sometimes referred to as a health record number
hybrid record
health record maintained in paper, electronic format, and or in the form of recordings or tracing derived from diagnostic tests
legal health record
the health record, identified by facility policy, that is considered the official business record and that would be presented if subpoenaed
electronic signature (e signature)
a digitized signature placed on a chart entry through the use of a personal identification number (PIN)
clinical documentation improvement (CDI)
the review of health records, usually concurrently, to ensure that the documentation in the health record is at the level of specificity that allows for code assignment that accurately depicts the patient’s diagnoses and procedures performed
reimbursement cycle
the processes that take place from the time a patient is registered for care to the time the services are paid, whither paid by the patient or through insurance
straight numeric (sequential) filing
records are filed in sequential numeric order
terminal digit filing
breaking a medical record number into segments of single or multiple digits, with filing based on the last segment as the primary file placement, followed by the middle segment, and then the first segment
WORM Technology
WORM is an acronym for “write once, read many” meaning that records may be read numerous times, but nothing on the disk can be altered in any way
client/server
the use of computers in a network where functions are split between server talks and client tasks; the client computer makes requests of the more powerful server computer in order undertake local processes
cloud-based solution
service in which software and data are stored on remote computers and accessed by a local computer through the internet, typically using a browser
record retention plan
a written policy that documents the length of time a health care facility retains its health records, the form (medium) in which the records will be kept, and the location(s) of the records
jukebox
a means of storing multiple optical discs using a robotic arm that loads and unloads optical disks for delivery of requested health records
disaster recovery planning
consists of having a back up infrastructure to support business continuity after a disruptive event. in healthcare, minimal recovery service levels are defined, such as access to patient records within a targeted time frame
Enterprise-wide MPI
health system
- may include one hospital and several ambulatory facilities, or it may include three or four hospitals and a hundred or more ambulatory facilities.
- the larger the enterprise the more difficult the task of ensuring the integrity of the MPI database
- MPI links a patient’s administrative data to the patient’s clinical data, found in the EHR
concurrent health record
“happening simultaneously”
developing health record that is compiled while the patient is hospitalized or being seen in an ambulatory setting
Give an example of EHRs allowing for the concurrent analysis of medical records
dictation and transcription with voice recognition technology
